Wellness Screening

1. Participant Information

Full Name *

Age (years) *

Date of Birth

Contact Phone *

Email

Gender

Primary Health Concern *

Duration of Main Concern

Treating Physician/Hospital (if applicable)

2. Absolute Contraindications Screening

Important: If any item below is checked, the participant is not eligible for this programme. Refer back to the treating physician.

Acute infection (fever, active COVID-19, TB)

Uncontrolled hypertension (>180/110 mmHg)

Acute cardiac event (MI, stroke, PE) within 3 months

Open wounds or active skin infections

Recent abdominal/pelvic surgery (<6 weeks ago)

Severe acute illness or hospitalization (current/recent)

3. Relative Cautions (Modify Protocol, Not Exclude)

Note: If any item below is checked, the participant can still enroll but the protocol must be modified. Document modifications carefully.

Severe pain or physical limitation

Joint/spine issues (arthritis, spondylosis, etc.)

Recent major medication changes or medical procedures

Severe anxiety, PTSD, or mental health condition

Immunocompromised or immunosuppression therapy

Pregnancy or recently postpartum

4. Current Health Status — Visual Analog Scale (0–10)

Rate each aspect: 0 = worst possible, 10 = best possible.

Sleep Quality

Poor Sleep Excellent Sleep

5

Overall Pain/Stiffness

Severe Pain No Pain

5

Mental Clarity/Focus

Fog/Confusion Crystal Clear

5

Energy Level

Exhausted Full Energy

5

General Well-being/Quality of Life

Terrible Excellent

5

Sense of Purpose/Meaning

No Purpose Strong Purpose

5

5. PHQ-9 (Depression Screening)

Over the last 2 weeks, how often have you been bothered by each problem?
0 = Not at all | 1 = Several days | 2 = More than half the days | 3 = Nearly every day

PHQ-9 Total Score: 0 / 27

6. GAD-7 (Anxiety Screening)

Over the last 2 weeks, how often have you felt anxious about each item?
0 = Not at all | 1 = Several days | 2 = More than half the days | 3 = Nearly every day

GAD-7 Total Score: 0 / 21

7. Current Medications, Supplements & Allergies

List all medications, supplements, herbs, and preparations currently being taken.

Medications & Supplements

Known Allergies (medications, herbs, oils, foods)

8. Informed Consent & Programme Expectations

Consent Statement

I understand that:

BAHRC Panchakarma and wellness programmes are therapeutic (supportive) in nature, not medical treatment or cure
These programmes complement, not replace, any medical care or treatment from my physician
All procedures are safe and reversible; I can discontinue at any time without penalty
My medical information will be kept confidential and used only for this programme and published research (de-identified)
I have discussed this programme with my treating physician or will obtain clearance if recommended
Results vary by individual; I should not expect guaranteed outcomes

I consent to participate in BAHRC wellness programmes

I consent to outcome measurement (questionnaires & assessments)

I consent to optional biomarker collection (if offered)

I consent to de-identified data being used in published research

Additional Health Information / Questions

BAHRC Wellness Screening Tool

Screening Summary

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