• Three Treasures Wellness Consultation 

    Intake Form

  • Contact Information

  • Format: (000) 000-0000.
  • Date of Birth *
     - -
  • How did you hear about us?
  • How did you receive this form?
  • Which Herbalist provided you with this form?

  • Your Goals 

  • In addition, please select all areas where you would like to optimize your health.

  • Current Medications and Supplements

  • Tongue Diagnosis

    In Traditional Chinese Medicine, the tongue shows what’s happening inside the body. Practitioners look at its color, shape, and coating because different parts of the tongue connect to different organs. Changes in the tongue can reveal imbalances, helping the practitioner decide on the best treatment.

  • LIFESTYLE 

  • How physically demanding is your job?
  • Do you exercise?
  • How often do you exercise?
  • Are you under a doctor’s care for any medical conditions?
  • How often do you consume alcoholic beverages?
  • Do you currently use tobacco products (cigarettes, cigars, etc.)?
  • Do you currently use marijuana or cannabis products?
  • How often do you consume caffeinated beverages (such as coffee, tea, or energy drinks)?
  • Do you currently use any recreational drugs (other than alcohol or marijuana)?

  • METABOLIC FUNCTIONS (Energy Production, Digestion, Assimilation, Elimination)

  • How would you rate your overall physical energy and stamina throughout the day?Type a question
  • Do you typically feel hot or cold when others do not?
  • Do your hands or feet ever become especially cold or hot?
  • Do you often feel warm at night or experience night sweats?
  • How would you describe your appetite?
  • Which best describes your general eating habits?
  • Do you follow any specific dietary preferences or restrictions? (Please select all that apply)
  • Are there any special dietary considerations you follow? (Select all that apply)
  • Which best describes your typical eating patterns?
  • Do you suffer from stomach acid or heartburn?
  • Do you usually find it easy to digest your food, without discomfort or issues?
  • Do you have any known issues with blood sugar levels, such as diabetes or hypoglycemia?
  • Do you experience any pain or discomfort during bowel movements?
  • Which of the following, based on the Bristol Stool Chart provided below, best describes your typical bowel movements?
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  • Do you experience excessive gas or bloating?
  • Do you experience any pain or discomfort in your digestive system (such as stomach pain, bloating, or cramps)?

  • MENTAL WELLBEING

  • How would you rate your ability to focus and concentrate?
  • How would you rate your short-term memory?
  • How would you rate your long-term memory?
  • Do you experience any of the following forms of stress? Select all that apply.
  • How often do you experience stress in the areas you selected?
  • How would you describe your ability to handle stress?
  • Does stress cause you physical tension (muscle tension) in your jaw, back and/or neck?

  • How frequently do you experience each of the following emotions?

  • Are you receiving therapy related to any of the above, or therapy related to depression?

  • SLEEP

  • How would you describe the quality of your sleep?
  • On average, how much sleep do you get each night?
  • Do you fall asleep easily?
  • Do you have trouble staying asleep?
  • Do you dream excessively?

  • URINARY FUNCTION, PERSPIRATION, SALIVA

  • Do you experience any discomfort when urinating?
  • Do urinary issues disturb your sleep?
  • Do you perspire easily?
  • Do you experience frequent dry mouth?

  • BIORHYTHMS 

    Biorhythms are your body’s natural cycles, like the daily rhythm that regulates your sleep, energy, and digestion. In TCM, we look at these patterns to understand if certain times of day consistently bring up symptoms or changes. This helps us identify potential imbalances and better support your body’s natural flow of energy.

     

  • Do you notice any recurring health-related symptoms or changes, good or bad, that tend to happen at certain times of day?
  • Do you take a regular nap?

  •  
    IMMUNE FUNCTIONS 

  • How would you rate your general immune strength or resistance to illness?
  • Do certain weather conditions often trigger immune responses for you?
  • Do you experience seasonal issues, such as allergies, hay fever, sinus congestion, or sensitivity to weather changes?
  • Do you catch colds frequently?
  • Do you experience recurring infections?
  • Do you have any known chronic infections, such as sinus, throat, stomach, skin, eye, mouth infections, or conditions like herpes, HIV, Hepatitis C, or CMV?
  • Are you currently experiencing any noticeable immune-related symptoms or issues?
  • Do you have allergies?
  • How would you describe the severity of your allergic reactions?

  •  
    RESPIRATORY FUNCTION

  • Do you have any history of lung-related health issues (e.g., asthma, chronic bronchitis, pneumonia)?
  • How would you describe your lung strength at this time?
  • Do you experience any breathing difficulties?
  • Do you often feel winded from walking up stairs or up a hill?
  • Do you have a chronic cough?
  • Have you ever been exposed to heavy smog or toxic air for an extended period?

  •  
    SKIN, HAIR, NAILS AND MICROCIRCULATION 

  • Which of the following best describes the condition of your hair?
  • How would you describe the condition of your fingernails?
  • Which of the following best describes the condition of your skin?
  • Does your nose appear redder than your forehead, either all the time or during certain situations (e.g., exercise, heat, or frustration)?
  • Is your skin excessively oily?
  • Do you bruise easily?
  • Does your skin heal quickly when scraped, bruised or cut?
  • Do your eyes become bloodshot when exercising or when it is hot?
  • Do you have noticeable bags or dark circles under your eyes?
  • Are your lips dry or cracked?
  • Have you been examined by a dermatologist recently?

  • STRUCTURAL - BONES, JOINTS AND CONNECTIVE TISSUES

  • To your knowledge, do you have any bone issues?
  • How would you describe your level of physical flexibility?
  • Do you have issues with any of your joints?
  • Do you have any specific range-of-motion issues?
  • Do you have lower back aches, instability, stiffness or pain?

  • INFLAMMATORY STATUS

  • Do you experience swelling in any part of your body?
  • Do you often feel stiffness or pain in your joints, especially in the morning or after periods of rest?
  • Do you experience frequent redness, warmth, or tenderness in specific areas of your body?
  • Have you been diagnosed with any chronic inflammatory conditions (e.g.,arthritis, IBS, eczema)?

  • CIRCULATION AND CARDIOVASCULAR  HEALTH

  • Are you aware of your current cholesterol levels?
  • Are your cholesterol levels within a healthy range, or have you been advised to manage them?
  • Do you know if your blood pressure is generally within a healthy range?
  • To your knowledge, have you ever experienced any issues with your heart rhythm?

  • TOXICITY

  • Have you been exposed to any environmental toxins or chemicals (such as pollution, pesticides, heavy metals) that may affect your health?

  •  
    CHRONIC PAIN 

  • Do you experience any chronic pain?
  • How would you describe the severity of your chronic pain?
  • Are your pains sharp or dull?

  • WOMEN

  • Is your menstrual cycle regular?
  • Do you experience any of the following around or during your menstrual period? Please select all that apply:
  • Are you currently pregnant, planning to become pregnant, or breastfeeding?
  • Have you experienced any fertility issues?
  • Are you experiencing any menopausal symptoms?
  • Do you use prescribed hormones?

  • MEN

  • Do you have any known prostate issues?
  • Do you experience any issues with sexual functioning, including libido or erectile dysfunction?
  • Do you have any known fertility issues?

  • SEX LIFE (this section is optional)

  • Are you satisfied with your current sex life?
  • How would you rate your current level of sexual desire or libido?
  • Do you experience any pain or discomfort during sexual activity?

  • AGING (for clients 40+)

  • How satisfied are you with your overall quality of life as you age?
  • Do you experience any issues with memory, focus, or concentration?
  • Do you experience any age-related physical discomfort or pain?(e.g., joint stiffness, back pain, muscle aches)
  • Have you noticed any changes in your skin, hair, or nails?(e.g., skin dryness, hair thinning, brittle nails)
  • Have you noticed any changes in muscle strength or physical endurance?
  • Have you noticed any changes in your vision or hearing?
  • Do you have concerns about maintaining a healthy weight?
  • Do you ever experience tremors?
  • Do you ever have dizzy spells or experience dizziness upon exertion or upon standing?

  • Client Acknowledgment and Wellness Disclaimer

    Dragon Herbs offers Traditional Chinese Herbalism wellness guidance and herbal product recommendations based on the information you voluntarily provide in this intake form.

    Your form may be reviewed by one or more licensed acupuncturists and trained herbal specialists. Their recommendations are intended to support general wellness, balance, and healthy function from a Traditional Chinese Herbalism perspective. They are not intended to diagnose, treat, cure, or prevent any disease or medical condition.

    The information and recommendations provided by Dragon Herbs are not a substitute for medical advice, diagnosis, or treatment from your physician or other licensed healthcare provider. If you have a medical condition, are pregnant or nursing, take prescription medications, are preparing for surgery, or have any concern about whether an herbal product is appropriate for you, you should consult your healthcare provider before using any dietary supplement or herbal product.

    Do not use this form for urgent or emergency medical concerns. If you are experiencing a medical emergency, call 911 or seek immediate medical attention.

    Dietary supplements have not been evaluated by the Food and Drug Administration. Dragon Herbs products are not intended to diagnose, treat, cure, or prevent any disease.

    By continuing, I acknowledge that:

    1. I have read and understand this disclaimer.
    2. I understand that Dragon Herbs is providing wellness and herbal product guidance, not medical diagnosis or treatment.
    3. I understand that I am responsible for consulting my healthcare provider regarding any medical condition, medication, pregnancy, nursing, surgery, or other health concern.
    4. I confirm that the information I provide is accurate and complete to the best of my knowledge.
    5. I authorize Dragon Herbs to use the information I provide to review my intake form and prepare wellness-oriented herbal recommendations.
    6. I agree to receive email marketing communications from Dragon Herbs, including wellness education, product updates, special offers, and company news, and I understand that I may unsubscribe at anytime using the link provided in the emails.
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