Date:

Name: Age:  Birth Date:

Address:

Home Phone:    Work Phone: Cell:

Height:   Weight: 1 Year Ago: 5 years ago:

Occupation: Full Time  Part-time

Living Situation: Alone  Friends  Partner  Spouse  Parents  Children  Pets

What are your major health concerns & intentions for your visit today?

Please list any other health care providers or consultants you are currently working with:

Please list any current health conditions diagnosed by a medical doctor:

When was your last physical exam? 

Please list all herbs, vitamins, and dietary supplements you are currently taking, including dosage and frequency:

List all medications you are currently taking (including aspirin, antacids, etc.) indicating whether they are over the counter (OTC) or Prescription, including dosage and frequency:

List all medications, herbs, foods, environmental factors, to which you have a known allergy:

• DIETARY INFORMATION

Describe below your typical meals. Please be as specific as possible. For example, instead of "oil" note type of oil such as olive oil, corn, etc. Instead of "bread" list whether white or whole grain, etc. Instead of "vegetables" list the type of vegetable, how prepared, canned, frozen or fresh, etc. Please include all beverages, type and quantity (two cups of orange juice, one cup of coffee, etc.)

Breakfast:

Morning Snack(s):

Lunch:

Afternoon Snack(s)

Dinner:

Daily water consumption (number of glasses/day):

Any recurring food cravings (such as salt, starch, sugar, chocolate, etc.) please list as many as applicable including time of day or month:

• FAMILY HISTORY

Please describe any relevant or major health related issues: (cancer, mental illness, diabetes, heart disease, etc.)

Mother:

Father:

Sister(s):

Brother(s):

Maternal Grandmother:

Maternal Grandfather:

Paternal Grandmother:

Paternal Grandfather:

•  MEDICAL HISTORY

List all major health problems including any operations:

• GENERAL HEALTH

  Select any of the following options that apply:
  Cardiovascular     
  Skin Muscles/Joints
  High blood pressure Boils
  Backache
  Low blood pressure
  Bruises Broken bones
  Pain in the heart
  Dryness Limited mobility
  Poor circulation Itch
  Arthritis
  Swelling
  Varicose veins Bursitis
  Stroke/murmur Skin
  eruptions Weakness
  Respiratory
  Urinary/Kidney
  Gastro/Intestinal
  Chest pain
  Excessive urination Belching
  Difficulty breathing Water
  retention Colitis
  Cough Bu
  urine Constipation
  Tuberculosis Kidneys
  stones Abdominal pain
  Congestion Lowe
  back pain Liver disorders
  Itchy ears/eyes
  Wheezing Gallstones
  Asthma Cir
  under eyes Ulcers
  Coughing up blood Blood
  in urine Digestive troubles
  Eyes, Ears, Nose and Throat
  Ear aches Eye
  pains Failing vision
  Hay fever Sinus
  infections Sinus congestion
  Sore throat Tonsi
  Hearing loss
  Canker sores
  Nosebleeds Difficulty
  breathing
  General
  Fatigue Night
  sweats Fever
  Male Reproductive
  Burning discharge
  lumps/swelling of testicles
  Painful testicles
  Vasectomy
  Female Reproductive
  Age of first period:
  Irregular cycles Pre-menopausal
  Heavy bleeding Blood
  clots Menopause
  Vaginal discharge Vaginal
  itching Pains/cramps
  Painful intercourse Vaginal
  dryness Pelvic pain
  Breast pain Breast
  lumps Anemia
  Infertility Gen
  Herpes Hot flashes
  Mood swings PMS
  Not able to conceive
  Contraceptive/Pregnancy History
  Birth Control Pills Rhythm-
  method I.U.D.
  Diaphragm Condoms
  Mucous-method
  Cervical Cap
  Spermicides Fertility lens
  

Please list each pregnancy you have had, including miscarriages:

  I am often not able to express my emotions.

  I am dissatisfied with my job.

  I am often stressed out and not able to cope properly.

  Even though I'm in a relationship, I often feel lonely.

  I often feel anxious and nervous for no good reason.

  I don't sleep well at night an have a hard time waking up in the morning.

  I often suffer from bad dreams and nightmares.

  There are many things I'd like to change in my life I just don't have the means.

  I have very low energy and often feel exhausted mentally & physically.

  I don't enjoy my work and would rather be doing something else.

  I find my children irritating and hard to relate to.

  I have very few hobbies.

  I often feel depressed for no reason.

  I often become angry with people and feel guilty about it later.

  I have a hard time letting go of the past

  I don't look towards the future with much enthusiasm.

  I am not able to concentrate for extended periods of time.

  My outlook is more negative than positive

  I spend a great deal of time worrying about what people think about me.

  I tend to see the good in people.

  I have a great sense of humor and love a good joke

  I receive great joy from my family.

  My outlook on life is positive.

  My job uses all my greatest talents.

  I have plenty of energy to do all the things I want.

  I sleep well at night and feel rested in the morning.

  I can concentrate on the task at hand for as long as it takes.

  I have a strong spiritual faith.

  I am able to express anger constructively

  I practice meditation or other relaxation techniques.

  I try to maintain peace of mind and tranquility.

  I have many close friends that I can always count on.

  I accept full responsibility for my actions.

  I trust my intuition and believe that things happen for a reason.

  I do not harbor any resentment from the past.

  I can feel completely fulfilled even if I'm alone.

  I have many hobbies and interests to keep me preoccupied.

  How I see myself is more important than how others see me.

  I often go out of my way to help others.

Do you engage in regular physical activity?    Yes     No

If yes, for how many minutes?   How often?

Do you smoke?  Yes   No

If yes, how much?   How often?

Do you drink alcohol?  Yes   No

If yes, how much?   How often?

Do you drink coffee and/or caffeinated beverages? Yes   No

If yes, how much?   How often?

How many hours of television do you watch in a week? 

Do you use artificial sweeteners?  Yes    No

Please use this space to add any other information about yourself that you think will be helpful:

• HERBALIST'S COMMENTS & SUGGESTIONS

Dietary Suggestions:

Recommended Herbs and Nutrients including dosage:

Lifestyle Modification Changes:

Relaxation techniques and exercise:

Other suggestions: