Questionnaire For Herbal Consultation
Basic Information
Name:
*
Gender:
*
Age:
*
Height:
*
Weight:
*
Phone Number:
*
Email:
*
List the issues that you would like to focus on with your herbal program:
Primary Concerns:
Secondary Concerns:
What medications (prescription or over the counter), herbal supplements, and vitamins are you currently taking, if any?
What, if any, health issues or medical conditions do you currently have and/or have had in the past?
Do you have any disease or other health issues that run in your family?
Are you currently under the care of a medical professional of any kind? If so, what does the practitioner specialize in and for which condition are you being treated?
Energy
How would you rate your overall daily energy from a scale of 1 to 10, with 10 being the highest level?
Digestion
Do you have consistent gas, pain, or bloating? If so, do these symptoms occur immediately after eating or at any time?
Do you suffer from acid reflux or heartburn?
How is your appetite?
How often do you have a bowel movement?
How are your bowel movements: loose, dry, normal?
Tell us any helpful details about your digestion that were not mentioned above.
Diet
Are you vegan or vegetarian or do you have any other dietary restrictions?
What foods do you typically eat?
Do you have any food sensitivities or allergies? If so, please list them.
Please include any other helpful details about your diet that were not previously mentioned.
Sleep
Do you have any issues falling asleep or staying asleep?
Do you feel rested upon waking?
How many hours do you sleep?
What time do you usually go to bed and wake up?
Tell us any other helpful details about your sleep that weren't mentioned above.
Breathing
Do you have any issues with your lungs or breathing in general?
If so, what are they?
Do you get shortness of breath?
Is your voice weak or strong?
Do you have a chronic cough?
Mental Energy and Well-Being
How is your mental focus and concentration?
Do you ever have brain fog?
Do you ever get dizzy or lightheaded?
How is your memory? Any issues with either your short-term or long-term memory?
How would you assess your emotional well-being? For example, do you tend to feel scattered, depressed, sad, anxious, or angry, or is any other emotion out of balance?
Do you worry a lot?
How is your creativity?
Do you have a lot of stress factors in your life?
If so, what are they?
On a scale of 1 to 10, with 10 being the highest level, what would you rate your stress level?
Physical/Other Issues
Do you have any issues with your skin?
If so, what are they?
Do you sweat spontaneously without heat or exertion?
Do you experience dryness in your mouth, scalp, or skin?
How is your hair thickness, luster, and color?
Do you have any issues with your nails, such as dry and brittle nails?
Do you have any issues with your vision or other trouble with your eyes, such as consistent dryness or red, irritated eyes?
Do you tend to feel cold, hot, or neutral in temperature in your body?
Do you often feel warm at night or even have night sweats?
Do you you get warmth/heat in the soles of your feet and/or palms of your hand?
Do you you get cold fingers and toes, although your body does not necessarily feel cold?
Do you suffer from lower back pain, knee pain, or weakness in your joints? If so, please list in detail what the issues are and how they affect you.
Do you have pain anywhere else in the body? If so, where?
Also, if you do have pain and had to rate the pain level on a scale of 1 to 10, with 10 being the worst pain, what would you rate it?
Do you have any issues with your hearing, such as loss of hearing or ringing in your ears?
Do you produce excessive amounts of phlegm?
Do you ever get a sticky feeling in your mouth?
Do you have a thick tongue coating?
Any unusual taste in your mouth that doesn't go away?
Do you retain water or have edema?
Do you bruise easily?
Do you carry a lot of tension in your upper back, shoulders, neck, or jaw?
Do you get sick often with flus, colds, or allergies?
Do you exercise?
How often?
If you do exercise, tell us some details about the kind of exercise you do.
Do you see any benefits from your exercise?
What kind of work do you do?
Is your job sedentary? Do you have to be on your feet a lot?
How many hours a week do you work?
Tell us about any other hobbies or other interests outside of your work.
Below are questions specifically for men or women
For women
How is your menstrual cycle? Is it regular?
Any pain, bloating, water retention, breast tenderness, or changes in mood before period?
Is your menstrual flow light, normal, or heavy?
Any clots?
Do you get menstrual cramps?
Any abnormal vaginal discharge?
Any issues with dryness or lack of sexual fluids?
How is your libido?
Any fertility issues?
Please tell us how many children, if any, you have. What are their ages?
For men
Tell us about your libido or other issues with sexual performance.
Any fertility concerns?
Do you have any issues with your prostate?
Please use the space below to tell us about any other issues or concerns that you feel are relevant that weren't covered in our questionnaire.
Signature
Save
Submit
Should be Empty: