General Herbal Medicine Consultation

General Herbal Medicine Consultation – Health ConnectShen

Please allow approximately 15–30 minutes to complete this consultation form. The information provided helps us prescribe safe and effective herbal medicine and provide personalised healthcare recommendations. Please provide your personal details, health history, and current concerns to help us tailor your herbal treatment plan. Senior Practitioner- Dr Nicky Macdonald (Chinese Medicine) .Please email at healthconnectshen@gmail.com with any questions or concerns.
Patient Details
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Clinic commitment and treatment expectations

HealthConnectSHEN is committed to providing professional, respectful, and individualized herbal medicine care. Treatment plans are based on the information you provide, and may include lifestyle guidance, herbal prescriptions, and follow-up recommendations. Results vary between individuals, and ongoing communication helps us support your care safely and effectively.
Acute Illness
Is this consultation for an acute illness such as cold, flu, cough, sore throat, sinus infection or other short-term illness?
Symptom onset
Fever or chills
Sweating
Sore throat
Cough type
Mucus colour
Sinus congestion
Body aches
Headache
Appetite
Hydration
COVID or flu testing
Current medications
Urgent symptoms
Chief Complaint and Treatment Goals
What is your main reason for seeking herbal medicine consultation?
What are your health goals or expectations from this consultation?
Current Medications, Supplements & Allergies
List any current medications (name and dosage):
List any supplements you take regularly:
Do you have any allergies (medication, food, environmental)?
Medical History
Do you have any chronic health conditions? Please specify.
Have you had any major surgeries or hospitalisations? Please list.
Is there any significant family medical history?
Review of Systems
Please tick any body systems where you have current symptoms or concerns:

Other
Lifestyle Factors
How would you describe your activity level?
Do you smoke or use tobacco?
How many alcoholic drinks do you consume per week?
How many caffeinated drinks do you consume per day?
Sleep, Stress, and Emotional Wellbeing
How many hours do you sleep per night on average?
How would you rate your sleep quality?
How would you rate your current stress level?

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
How would you describe your general emotional wellbeing?
Digestive Health
Do you experience any of the following digestive symptoms?

Other
Pain and Energy Levels
Do you experience pain? If yes, please describe the location, nature, and frequency.
How would you rate your current energy level?

1

2

3

4

5

6

7

8

9

10

1 is Very Low, 10 is Very High
Traditional Chinese Medicine Constitutional Questions
Do you prefer warmth or coolness?
Describe your usual thirst (amount and preference for hot or cold drinks):
Do you sweat easily? When and where?
How is your appetite?
Do you experience any digestive issues (e.g., bloating, irregular appetite, discomfort)?
How would you describe your stools (frequency, consistency, colour)?
Describe your urination (frequency, colour, any issues):
How would you describe your general mood and emotions?
Describe your sleep patterns (ease of falling asleep, staying asleep, waking):
Describe the appearance of your tongue (colour, coating, shape):upload a photo of your tongue
Upload Photos and Reports if relevant. Upload photo of tongue here also.

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Additional Information
I confirm the information provided is accurate and complete
Practitioner Notes
Should be Empty:

General Herbal Medicine Consultation – Health ConnectShen

Patient Details

Acute Illness

Chief Complaint and Treatment Goals

Current Medications, Supplements & Allergies

Medical History

Review of Systems

Lifestyle Factors

Sleep, Stress, and Emotional Wellbeing

Digestive Health

Pain and Energy Levels

Traditional Chinese Medicine Constitutional Questions