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Full Name

First NameLast Name

Address you would like your Chinese herbal formula to be shipped to

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date

MonthDayYear

Phone Number

Area CodePhone Number

Gender

Height

Weight

Email Address

What are the main health concerns that you would like addressed today?

Do you have any known allergies?

Are you currently taking any prescription or over the counter medication, or herbal, vitamin, or mineral supplements of any kind?

Have you had any surgery in the past? Please list all, related or not to your chief complaint today.

Do you fall asleep easily, stay asleep through the night and wake feeling rested?

Do you notice a specific time frame that you regularly wake up during the night?

Do you have good energy through out the day? What time is it lowest?

How many caffeinated beverages do you consume throughout the day?

Do you have a solid, complete bowel movement every day? How often/how many times per day?

Do you have any pain, difficulty, loose stool, bloating, excessive gas or other gastrointestinal problems?

Do you have any shortness of breath or difficulty breathing? Coughing, congestion in lungs or sinus? What color is the mucus?

What is the color of your urine (dark yellow, medium, light, clear, etc)

Do your hands and feet feel warm, cold, or neutral in temperature?

When you touch your hand to your forehead, which is warmer, your face or your hand?

Do you have any abnormal sweating? (Difficult to sweat, too easy to sweat, night sweats, cold sweats etc?)

How is your appetite? Too much, too little, any specific cravings?

Are you thirsty? What temperature water do you prefer?

Do you experience any nausea, dizziness or headaches? How often?

Do you tend toward any particular emotion in excess (anger, anxiety, depression, over-excitement, worry/over thinking etc)?

For women: do you have a regular monthly menstrual cycle? If post-menopausal, how long? How many days is your cycle? How many days does your menstrual period last? Is the bleeding heavy, moderate, light? Any symptoms associated with it (fatigue, irritability, breast distention, headaches, dizziness, cramping, blood clots etc)?

Any other questions, concerns or symptoms you would like to mention?

I understand that a Custom Chinese Herbal formula is not intended to replace any conventional medical care I may be receiving. I also understand that this consultation and herbal formula are not intended to diagnose, treat, or cure any health condition. I am aware that my Chinese herbal formula will be a custom blend of safe, all natural minerals and herbs that are intended to be used as a nutritional supplement to promote balance within the body. A complete list of ingredients is always available to me upon request. I understand that I should be under the care of a Medical Doctor for any health condition that I may have and that Hayley Gardner, Licensed Acupuncturist, is not to be held responsible in any way for my neglect to seek medical attention or for the mismanagement of these conditions as a result.

Chinese Herbal Medicine Long-Distance Consultation Form