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Personal Health History Questionnaire

Personal Health History Questionnaire

* This document has been secured with a HIPAA-compliant asymmetric encryption algorithm to guarantee the confidentiality of your health information.

Filling out this form as completely and thoroughly as possible will ensure that your consultation with Dr. Lonsdorf will be efficient and beneficial. This usually takes about 20-30 minutes. Please have your health information, medications and supplements handy when you sit down to fill it out.

Please complete it at least 3 full days prior to your consultation, so we can enter the information into your electronic health record and Dr. Lonsdorf has time to review it ahead of your session.

Thank you!

* NOT FULLY COMPATIBLE WITH FIREFOX WEB BROWSER *

Personal Health History Questionnaire

We would love to hear from you! Please fill out this form and we will get in touch with you shortly. Make sure you see the "Thank You" - page after submitting the form. If you don't check that you have filled out all required fields.

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NOTE! YOU MUST WRITE CONTINUOSLY TO THE END or this form may time out and you will lose all your information.

IF YOU MUST STOP FOR A FEW MINUTES….

CLICK ON THE GREEN SAVE AND CONTINUE LATER button (always present at the bottom right corner of this window). A popup will ask you to enter your email address, and it will then email you a link you can click on when you are ready to continue. Otherwise you will LOSE all you have entered as this form times out (we have no control over that, unfortunately.)
Section 1: Select Consultation Type
In person phone and office visits:
- New: Phone (“Wellness”)
- New: In Person - New to Ayurveda
- New: In Person - Prior Maharishi Ayurveda consultation
- Returning: In Person - Office Visit
- Returning: Phone Consultation
How did you hear about us?
Section 2: Secure Communiction
I request that all communication, including lab orders and other personal health information, be sent to me by:*
- Confidential patient portal (“Updox” is the name of this practice’s portal)—I understand I will need to make a username and password to access my private portal account.
- Email (I understand that email is not private and my information is subject to hacking or other possible non-secure disclosure)
Section 3: Contact Information and Vital Statistics
Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Daytime Phone (Please give best phone #(s) to contact you.) OLD
Cell Phone OLD
Daytime Phone (Please give best phone #(s) to contact you.)
Cell Phone
Evening Phone
Email*
Would you like a receipt to submit to your insurance company for your consultation today?
- Yes
- No
(Please note that this practice does not accept Medicare or Medicaid and most insurance companies do not cover phone or Skype consultations.)
Do you have long-term care insurance (i.e. for nursing home, or other extended care facility)?
- Yes
- No
Are you enrolled in Medicare?
- Yes
- No
Emergency Contact
Relationship*
Do not have an emergency contact
- Do not have an emergency contact
Phone*
(###) ###-####
Name*
First Last

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Vital Statistics
Age
Height
Weight
Blood pressure, recent readings
Date of reading
Month
Day
Year
Date of Birth
Marital status
- Single
- Married
- Divorced
- Separated
- Widowed
Genetic Sex*
- Male
- Female
Gender
Preferred pronouns
Ethnicity
Race
What is your occupation?
If retired, please list past occupation(s):
What are your usual working hours?
Number of children
Ages of children

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COVID-19 Vaccination
Have you been fully vaccinated against COVID-19?
- Yes
- No
- 1 of 2 shots completed
If "yes," which vaccine did you receive?
Please give the date of your last COVID vaccine shot:

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Section 4: Wellness Issues, Medications and Supplements
Please list any health conditions you have in order of severity. (You may enter up to 4 wellness issues.)
Wellness Issue 1
Severity Level
- Severe
- Moderate
- Mild
Length of Time
- > 5 years
- 1-4 years
- < 1 year
Progress
- Getting better
- Getting worse
- Staying the same
Wellness Issue 2
Severity Level
- Severe
- Moderate
- Mild
Length of Time
- > 5 years
- 1-4 years
- < 1 year
Progress
- Getting better
- Getting worse
- Staying the same
Wellness Issue 3
Severity Level
- Severe
- Moderate
- Mild
Length of Time
- > 5 years
- 1-4 years
- < 1 year
Progress
- Getting better
- Getting worse
- Staying the same
Wellness Issue 4
Severity Level
- Severe
- Moderate
- Mild
Length of Time
- > 5 years
- 1-4 years
- < 1 year
Progress
- Getting better
- Getting worse
- Staying the same

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Past Health History
Are you allergic to any drugs or medications?
Please list any foods or spices you are allergic to or cannot tolerate.
If allergic, what reaction(s) did you have?
If had allergic reaction(s), how serious was it?
Please list all surgeries, hospitalizations and serious illnesses and injuries you have had.
Please list all serious disorders that run in your family and their relation to you (i.e., mother, brother, etc.).
Prescription Drugs
How often and for about how long have you taken antibiotics in the past?
Below please list prescription drugs you take, including all hormones, the dosage, and the length of time you have taken them.
Please list supplements you take and length of time you have taken them.

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Section 5: Lifestyle & Health History Questionnaire
How is your sleep?
- Insomnia most nights
- Occasional insomnia
- Good
What time do you usually go to sleep?
- By 10 PM
- 10-11 PM
- 11 PM to midnight
- After midnight
What time do you get up?
- Before 6 AM
- 6-7 AM
- After 7 AM
Approximately what date was your last physical exam?
MM slash DD slash YYYY
Have you had a colonoscopy?
- Yes
- No
When was your last one?
MM slash DD slash YYYY
Was it completely normal? Any polyps or other abnormalities found?
How many bowel movements do you normally have a day?
- Less than 1
- 1
- 1-2
- More than 2
Is the stool hard, medium, soft or loose?
- Hard
- Soft
- Medium
- Loose
Are they easy or with strain?
- Easy
- With strain
Do they alternate between constipated and loose?
- Yes
- No
Do you have hemmorhoids?
- Yes
- No
If yes, do they bleed?
- Yes
- No
Have you had a recent change in bowel habits?
- Yes
- No
Do you have blood in your stool or black stools?
- Yes
- No
Do you feel now or in the past you have had an eating disorder? Please describe briefly if the answer is yes.
Do you have problems with gas or bloating?
- Yes
- No
Do you get heartburn or reflux regularly?
- Yes
- No
Do you have sour stomach or acid indigestion regularly?
- Yes
- No
Do you feel heavy after eating?
- Yes
- No
Do you feel sleepy after eating?
- Yes
- No
How is your appetite?
- Strong
- Weak
- Variable
How is your energy during the day?
- Strong
- Weak
- Variable
Do you have night sweats?
- Yes
- No
Do you have frequent urination?
- Yes
- No
Do you have urinary urgency or leakage?
- Yes
- No
Do you have numbness or tingling in hands or feet?
- Yes
- No
Have you lost or gained weight in the last 6 months and if so how much?
- No change
- Lost less than 5 pounds
- Lost 5-10 pounds
- Lost more than 10 pounds
- Gained less than 5 pounds
- Gained 5-10 pounds
- Gained more than 10 pounds
What percentage of your food is from leftovers?
- Less than 10%
- 10-30%
- More than 30%
What percentage of your food is organically grown?
What percentage of your food is frozen or packaged food?
- Less than 10%
- 10-30%
- More than 30%
How often do you eat out in a restaurant each week?
- 0-3 times
- 3-7 times
- More than once a day
How often do you microwave a week?
How many times do you eat meat a week?
- None
- 1-3 times
- 3-7 times
- More than once a day
Please list any foods that you are intolerant to.
How many alcoholic beverages do you consume per day?
- 0
- 1
- 2 or more
Please describe current and past use of recreational chemicals (marijuana, LSD, cocaine, ecstasy, etc).
How many caffeinated beverages on average do you consume per day on average?
- 0
- 1
- 2-5
- More than 5
If you smoke how many cigarettes do you smoke a day?
- 0
- 1-10
- 10-20
- More than 1 pack
Are you having memory issues?
- Yes
- No
If you answered "yes" to having memory issues, please describe.
Are you having balance issues (unsteadiness)?
- Yes
- No
If you answered "yes" to having balance issues, please describe.
Do you have a tremor?
- Yes
- No
If you answered "yes" to having a tremor, please describe.
How many diet sodas or other products containing aspartame do you drink a day?
- 0
- 1
- 2-5
- More than 5
How often a week do you exercise (at least a brisk walk for 30 minutes or longer)?
- 0
- 1-2
- 3-5
- >5
Do you practice meditation or relaxation techniques daily?
- Yes
- No
If you answered yes above, what type of meditation or relaxation techniques do you use?
Are any of the following moods an issue for you? You may choose more than one.
- Depression
- Anxiety
- Anger or irritability
Are you having work or family problems that are significantly affecting your health?
- Yes
- No
Which lifestyle changes are you most interested in making at this time?
- Diet
- Sleep
- Exercise
Please list when you have breakfast and what you normally eat.
Please list when you have lunch and what you normally eat.
Please list when you have dinner and what you normally eat.
Please list when you have snacks and what you normally eat.

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Environmental Health
What direction does the main entrance to your house face?
- North
- South
- East
- West
What side of the house do you enter?
- North
- South
- East
- West
What direction does the head of your bed point to?
- North
- South
- East
- West
Do you live near a power plant or high tension wires?
- Yes
- No
How many hours a day do you use your computer (number, not a range)?
How many minutes a day do you use a cell phone (number, not a range)?
Do you place the phone up to your ear?
- Yes
- No
Toxin Exposure and Sensitivity
Do you feel you are highly sensitive to chemicals?
- Yes
- No
Do you use mostly organic personal care products, fragrance free laundry products, and non toxic cleaning products in your home?
- Yes
- No
Are you exposed to chemicals, pesticides or toxins on a regular basis?
- Yes
- No
Have you recently renovated, or painted your home or office?
- Yes
- No
Are you exposed to mold, mildew regularly?
- Yes
- No
Had water damage in your home/office that was not fully remediated?
- Yes
- No
Does your home or office have a "musty odor"?
- Yes
- No
Do you get condensation (with or without mold) on the window edges or in your shower?
- Yes
- No
Women's Health
Your menstrual cycles are?
- Regular
- Irregular
- Stopped
When was your last menstrual period?
When was your last Pap smear?
- Within the last year
- 1-2 years ago
- Over 2 years ago
When was your last mammogram?
- Within the last year
- 1-2 years ago
- Over 2 years ago
Have you reached menopause (i.e., is it over 1 year since your last period)?
- Yes
- No
Are you experiencing any problems with periods or menopause? Please describe.
How many pregnancies have you had?
Number of miscarriages?
Number of abortions?
How many live births?
Please comment on any question above or describe any other aspects of your health or your life you feel it is important for Dr. Nancy to know.

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Section 6: Please describe what you hope to achieve from your consultation.
Outcome 1
Outcome 2
Outcome 3
If you are having a phone or Skype consultation, please fill out sections 6, 7 and 8. If you are coming for an office visit, it is recommended but not required that you fill out sections 6 and 7, and you may skip to Section 8 if you wish."
Section 7: AMA Questionnaire
Check each of the following signs of accumulated “ama” or metabolic blockage that applies to you.
- You wake up tired even after a good night's sleep.
- You feel lethargic.
- Your tongue is coated.
- You have too much saliva.
- You don't feel real hunger, even when you haven't eaten for several hours.
- You have generalized aches and pains.
- You lack mental clarity and energy.
- You feel a sense of heaviness in the abdomen, arms, or legs; or in the body as a whole
- You feel weary and unenthusiastic.
- You experience frequent indigestion, such as gas, bloating or heartburn.
- You feel blocked anywhere in the body, including constipation, sinus congestion, and difficulty breathing.
Section 8: Your Dosha Balance (for Women)
V Type:
- Gas or bloating
- Hot flashes
- Feeling cold or cooler than normal
- Forgetfulness
- Easily distracted
- Crying spells
- Tension headache
- Irregular cycles
- Urinary urgency, frequency or leakage
- Irregular heartbeat or palpitations
- Fluctuating blood pressure
- Trouble getting to sleep
- Joint pains or muscle aches
- Low libido
- Vaginal dryness
- Anxiety or excessive worry
- Mood swings
- Dry swings
- Constipation
P Type:
- Anger or irritability
- Frequent bowel movements or loose stools
- Skin rash, rosacea or acne
- Unpleasant body odor
- Urinary tract infections
- Difficulty getting back to sleep if wake up at night
- Night sweats or sweating during the day
- Hot flashes
- Feeling warmer than usual when not flashing
- Heavy bleeding
- More days of heavy flow than usual
- Migraine headaches
K Type:
- Excessive weight gain
- Fluid retention
- Breast swelling or fullness
- Abdominal heaviness
- Food "sits there," slow to digest
- Stiffness or heaviness in the body
- Lethargy
- Lazy or unmotivated feeling
- Depression or melancholy
- Elevated cholesterol
- Yeast infections
- Excess mucus, allergies or sinus problems
- Asthma, bronchitis or chronic cough

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Section 8: Your Dosha Balance (for Men)
- Anxiety or excessive worry
- Moodiness
- Dry skin
- Constipation
- Easily feeling cold or cooler than others
- Forgetful
- Easily distracted
- Tension headaches
- Low back pain
- Gas or bloating
- Urinary urgency, frequency or slow stream
- Erectile dysfunction
- Low libido
- Irregular heartbeat or palpitations
- Fluctuating blood pressure
- Trouble getting to sleep
- Joint pains or muscle aches
P Type
- Easily feeling hot or warmer than usual
- Migraine or cluster headaches
- Anger or irritability
- Over-aggressiveness, “pushy”
- Frequent bowel movements or loose stools
- Skin rash, rosacea or acne
- Unpleasant body odor
- Urinary tract infections, include prostatitis
- Frequent or profuse sweating
- • Difficulty getting back to sleep if wake up in the night
K Type
- Excessive weight gain
- Fluid retention
- Abdominal heaviness
- Food “sits there,” slow to digest
- Stiffness or heaviness in the body
- Lethargy
- Lazy or unmotivated feeling
- Depression or melancholy
- Elevated cholesterol
- Excess mucus, allergies or sinus problems
- • Asthma, bronchitis or chronic cough
Section 9: Informed Consent Agreement
1. I understand and agree that I am undertaking involvement in an Ayurvedic educational program by phone, internet videoconference or in person. I understand that what I will be receiving will be educational information as to the Maharishi Ayurveda approach to health, which uses a unique system of evaluation and treatment based on the concepts of balance, doshas and overall tissue health to enliven and balance the inner intelligence of the body. I understand that unless and until I have a direct, in-person consultation with Dr. Lonsdorf, I will not be participating in a medical consultation or become Dr. Lonsdorf's patient or have a patient-physician relationship with Dr. Lonsdorf. Until I consult in person, Dr. Lonsdorf will be unable to write prescriptions for me and unable to order tests for diagnostic purposes. [NOTE: During the COVID crisis, most states allow telehealth or telemedicine virtual visits for initial consultations, including for licensed doctors from out of state, i.e. not licensed in the state the patient is physically located in at the time of the consultation. In such a case, some test orders, and insurance receipts for telemedicine visits etc may be lawfully provided.]*
- Agree
- Disagree
2. I also understand that the Maharishi Ayurveda knowledge I receive in any consultations with Dr. Lonsdorf, including such information as I may receive during an in-person visit as a patient of Dr. Lonsdorf, is educational information only and is NOT a substitute for modern medical evaluation, diagnosis or treatment nor is it a substitute for conventional preventive testing (such as blood tests, Pap smears, mammograms, colon cancer screening and any other appropriate screening tests.) I understand that the Maharishi Ayurveda educational information I will receive is also NOT for the purpose of diagnosing or treating any disease that I may have. For the treatment of any diagnosed disease that I may have, I agree to continue under the care of my family doctor and continue to seek the advice of any specialists with whom I have consulted.*
- Agree
- Disagree
3. In the case that I have not seen Dr. Lonsdorf in person within the last year, I understand that any lab test orders provided to me by Dr. Lonsdorf are for overall wellness assessment purposes only. I understand such tests are not for the purpose of preventing, diagnosing or treating a disease, and only for my personal education regarding my wellness. I understand that by executing this order for a lab test, I am not entering into a patient-doctor relationship with Dr. Nancy Lonsdorf. If any abnormal test results are found, I agree to notify my local doctor and request his or her professional advice as to how it should be address medically.*
- Agree
- Disagree
4. I agree not to modify or suspend any medical treatment program that I am now receiving, based on the information I receive. I understand that if I have a specific medical condition, I am advised to review all options, approaches and treatment modifications discussed in this session with my personal physician before implementing them in my health program.*
- Agree
- Disagree
5. I understand that it is very important that I provide information that is as accurate and complete as possible. If I am aware of or have been advised by any physician that I am suffering from any disease or disorder, I agree that I will disclose this information to the physician in writing in this questionnaire. I also agree to disclose any medication or treatments that I am currently receiving.*
- Agree
- Disagree
6. I understand that the Maharishi Ayurveda programs have been developed in part by Ayurvedic scholars associated with universities or other institutions. However, I recognize and agree that any advice or recommendations to me are the sole responsibility of Dr. Nancy Lonsdorf and no other person or organization.*
- Agree
- Disagree
7. I understand that any herbal food supplements recommended for me are not drugs and do not treat any disease. Any other programs recommended also do not treat any disease, but are alternative approaches which are for the purpose of specifically balancing the doshas, or underlying intelligence of the physiology, for the purpose for creating balance in the physiology and improving overall mental and physical well-being.*
- Agree
- Disagree
8. I understand that any herbal food supplements and other treatments and recommendations that I may be recommended have not been evaluated by the Food and Drug Administration nor are these approved by the FDA for the prevention, diagnosis, treatment or cure of any disease condition.*
- Agree
- Disagree
9. I understand that while the recommendations of the Maharishi Ayurveda program are usually free of harmful side-effects, I am aware that individuals can react differently to diet, spices, herbs and lifestyle changes. I understand that I am advised to consult my personal physician before implementing them or changing my diet. If I use them I am electing to adopt these suggestions at my own risk. I further understand that such suggestions and treatments are not medically necessary for my condition, and that the physician's liability insurance may not cover adverse outcomes that may occur with these treatments.*
- Agree
- Disagree
10. Privacy Policy - I affirm that I am hereby notified of the downloadable Practice’s Privacy Policy in pdf form, which is located along with the Practice Brochure on Dr. Lonsdorf’s website at http://ayurveda-ayurvedic.org/before-your-appointment/. I understand that I may additionally request a printed version of this Privacy Policy, which will be handed or mailed to me.*
- Agree
- Disagree
11. Fees - I agree to pay at the time of booking or time of service, as described in the Fee Schedule, all fees that I incur, or which are incurred on my behalf. I understand that such fees may change without notice, however any agreed-upon package or program that I have started will be honored through its duration as stated in the materials I received. I have read the current fee schedule provided to me and agree to all terms, including cancellation and refund policies, overtime fees and fees for email responses beyond those included in the program (responses requiring doctor’s review and input are limited to 2 weeks after each visit.)*
- Agree
- Disagree
12. 48 hr Notice Requirement - I understand that NKL, MD PC requires 48 hours notice for a cancelled appointment. If I fail to give notice (i.e. “no show,”) or give less than 48 hr. notice regarding a cancellation, I agree to pay NKL, MD PC the current late cancellation fee for each cancelled consultation.*
- Agree
- Disagree
13. Medicare Non-Acceptance- I understand that NKL MD, PC has opted out of Medicare, and I agree that I will not submit any claims to Medicare in any circumstances. This prohibition applies even in the case that a secondary insurer may require claims first be submitted to Medicare before they will cover any services that Medicare will not.*
- Agree
- Disagree
14. I recognize that no claims or guarantees have been made to me regarding specific medical benefits or improvement in my medical condition(s) that I will receive as a result of any Maharishi Ayurveda Educational information I may receive. I understand and agree that, notwithstanding anything to the contrary in this agreement, the limit of liability of Dr. Lonsdorf for any services provided to me, including Maharishi Ayurveda educational services or physician-patient services, shall not exceed five times the amount paid to Dr. Lonsdorf by me for such services. This agreement shall be governed by the internal laws of the state of Iowa and not its conflict of laws principles.*
- Agree
- Disagree
15. While email may be used to schedule appointments and for clarifying non-medical recommendations, such as diet or lifestyle, Dr. Lonsdorf and her staff do NOT send Personal Health Information via email, and strongly advise you to use the secure "Myupdox" portal to send us any health information (lab test results, diagnoses, etc) . If it is not feasible for you to communicate health information to us through your "Myupdox" secure portal, exceptions to this policy might be granted at our discretion with your written request. In such as a case, client/patient agrees to assume the risk and accept the consequences of such breaches.*
- Agree
- Disagree
16. While Skype and Zoom communications are encrypted, they are not secure patient web portals according to HIPAA standards. No guarantee can be made that the Skype and Zoom service protects users’ data or the content of communications or that it is secure from third-party “hackers.” While Dr. Lonsdorf and her staff take reasonable precautions with the information under their control, interception or misuse of client communications over Skype and Zoom, while unlikely, are possible. I, the client, agree to assume the risk and accept the consequences of such breaches, or alternatively, to request a telephone consultation if I do not wish to incur these risks.*
- Agree
- Disagree
17. I understand that no medical or health issues will be addressed that involve an ongoing or contemplated lawsuit. I agree not to bring such medical issues for evaluation or treatment by Dr. Lonsdorf*
- Agree
- Disagree
18. Billing for Additional Minutes — I understand and agree to pay the hourly rate, as quoted in my confirmation email, for any additional consultation minutes that accrue beyond the time originally scheduled and already paid for, for my one-time visit or, if part of a consultation package, the actual consultation time in addition to that allotted for as described in the flyer I received. I understand I will be informed by email after the consultation regarding the total of any additional minutes and the amount of any additional charge to my credit card, which I hereby authorize to be charged automatically.*
- Agree
- Disagree
19. I have been informed that "The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov."*
- Agree
- Disagree
This agreement is intended to have legal significance.
NOTE: Click the “Submit” button below to submit it.

AFTER SUBMITTING, if you see the Thank You page with the lotus flower, your form will be encrypted and saved and the doctor can access it.

If after submitting you remain on this page, then be sure to scroll up and complete the required questions you may have missed. These will be highlighted in red.

IF YOU HAVE PROBLEMS, PLEASE CONTACT US AT 641-469-3174.
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Nancy K. Lonsdorf, MD
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