Deoshala Panchakarma Intake

01 Personal Information

Full Name

Date of Birth

Nationality

Current City / Country

WhatsApp / Phone

Email

Occupation

Preferred Panchakarma Dates

02 Body & Vitals

Height

Current Weight

Weight 12 Months Ago

03 Health History

Diagnosed Conditions

Diabetes Hypertension Thyroid Disorder Cardiac Condition IBS / IBD Mental Health Condition

Surgeries or Hospitalisations

Current Medications & Supplements

Allergies

04 Digestion & Elimination

How would you describe your digestion?

Bowel Movements Per Day

Consistency

05 Sleep & Energy

Average Hours of Sleep

Wake Feeling Rested?

06 Diet & Lifestyle

Diet Pattern

Omnivore Vegetarian Vegan Pescatarian

Typical Daily Meals

Coffee / Caffeine Per Day

Alcohol Per Week

Water Intake (Litres)

07 Skin, Hair & Head

Current Symptoms

08 Movement & Training

Current Training Pattern

Yoga or Breathwork Experience

09 Mind & Emotion

Stress / Overwhelm (1-10)

Anxiety / Restlessness (1-10)

Low Mood / Sadness (1-10)

Irritability / Anger (1-10)

What brings you to Panchakarma now?

What would a successful outcome look like in six months?

Anything else you'd like us to know?

10 Reproductive Health (Optional)

Cycle Length (Days)

Date of Last Period

Regular or Irregular Cycle?

PMS / Cycle Related Concerns

11 Previous Healing Experience

Have you done Panchakarma before?

If yes, describe your experience

Other healing or therapeutic modalities you have explored

12 Logistics & Preferences

Preferred Program Duration

Available Start Dates

How did you hear about Deoshala?

Emergency Contact

Upload Medical Reports (Optional)

13 Consent

Where will client responses go?

Right now, the form is connected to Formspree. Once you create a free Formspree account and replace YOUR_FORM_ID, every submission will automatically arrive in your email inbox.

You can also connect the form to:

Google Sheets (automatic spreadsheet entries)
Notion or Airtable
WhatsApp or email notifications
Private client dashboard later

Recommended setup for now: Formspree + Google Sheets. Simple, elegant, no server headaches. Humanity already created enough of those.