Consultation Form Basics Name: Phone: Email: Age: Weight: (required if under 16) Hight: (required if under 16) Goals: Order most to least important Next Career What do you do for a living? How many hours do you work? Do you enjoy your work? Yes, I enjoy my work most of the time No, I do not enjoy my work most of the time Sometimes, I enjoy my work about 50% of the time How stressful is your work? 1 none 2 3 4 5 Manageing 6 2 8 9 10 Overwelmed Life Do you have a significant other? Yes, I have asignificant other No, I do not have a significant other Do you have support people? Yes, I have support people No, I do not have support people Kids? No Kids Do not want more kids Want more kids Kid(s) live with me Some Kid(s) live with me Kid(s) do not live with me 1-2 kids 3-4 kids More than 4 kids What does your average day look like? What does your stress level on an average day look like? 1 none 2 3 4 5 Manageing 6 2 8 9 10 Overwelmed What does your stressful day look like? What does your stress level on an stressful day look like? 1 none 2 3 4 5 Manageing 6 2 8 9 10 Overwelmed What does your good day look like? What does your stress level on an good day look like? 1 none 2 3 4 5 Manageing 6 2 8 9 10 Overwelmed What do you do for fun? What do you do to relax/releaive stress? On average how many times to you get sick in a year? How long do you stay sick when you get sick? When you get cuts or bruising on average how fast do they heal? Sleep How many hours on average do you sleep a day/night? 1 2 3 4 5 6 2 8 9 10 How many hours of sleep would you like to have day/night? 1 2 3 4 5 6 2 8 9 10 What is the quality of your sleep? Wake Refreshed Wake in the night Trouble falling asleep Wake tired When do you go to bed? When you wake up? What are you dreams like? Do not remeber Remeber them well Remeber some Scary Stressful Happy Next Health and Preferences Conditions/Diagnosis: Name Year started What do you do for it? Medications/ Prescibed drugs: Name Dose/Frequency Date started Reason Vitamins: Name Dose/Frequency Date started Reason Herbs: Name Dose/Frequency Date started Reason List any family conditions you are worried about: Relation condition Reason Allergies: Allergien What happens Are you pregnant? Yes, I am currently pregnant No, I am not currently pregnant maybe, It is possible I am pregnant Preferences: Do you prefer a method of taking herbs internally? Tea/Decotion Powder (mix into food or drinks) Tincture with alcohol Tincture with Gylcerin Food- in a jam, honey, fruit leather etc. Other Do you have any methods of taking herbs internally that you will/can not do? Tea/Decotion Powder (mix into food or drinks) Tincture with alcohol Tincture with Gylcerin Food- in a jam, honey, fruit leather etc. Other Do you have any methods of taking herbs externally that you will/can not do? Lotion Bath Steem Other What flavors do you like? Bitter Sweet Earthy Umami Salty Astringent Sour Pungent Other What flavors do you not like? Bitter Sweet Earthy Umami Salty Astringent Sour Pungent Other Next Diet What are your meals on a good day? (ex. breakfast-Protein, lunch-greens, dinner-protein, fat, & greens) What are your meals on a bad day? (ex. breakfast-Protein, lunch-greens, dinner-protein, fat, & greens) With in a week How often do you consume the below on average: Vegetables (carrots, spinach, potato...) Fruit (orange, apple grapes...) Saturated fat (lard, butter, solid fat...) Non saturated fat (vegetable oil, olive oil...) Meat (chicken, pork, beef...) Fish (salmon, tilapia...) Meat (chicken, pork, beef...) Fish (salmon, tilapia...) Legumes(peanuts, beans, peas...) Nuts and seeds (pumpkin seeds, walnuts...) Whole grains (Rice, Oats, wheat...) Baked goods (bread, doughnuts, cookies...) Fermented foods (Kimchi, Miso...) Sugary (candy bars, gummies...) Dairy (milk, cheese, yogurt...) Juice (Koolaide, fruit juice...) Water Sodas (pepsi, cocola, sprite...) Alcohol (mixed drins, beer...) Caffeine (Cofee, Energy drinks...) Do you have variety in your diet? Yes, I eat many different kinds of each food catigory each week No, I eat relitivly same or simlar kids of each food catigory each week Varies, I sometimes eat lots of variety somtimes I eat simalar foods all week Unsure Next Energy/Dosha Physical Traits Fast, wondering speech Eyes tend toward dryness Small, darting eyes Light/thin frame Lose weight easily Muscle stiffness Sharp, to the point speech needs glasses/contacts Sensitivity to light Yellow or red sclera Burning/bloodshot eyes Sharp, piercing gaze Creaky joints Medium frame Maintain weight easily Muscle tension Good muscle development Sweet, slow speech Thick eyelashes Large, moist eyes Blue tinted sclera Broad frame Gains weight easily Flexible Preferences Love to travel Live in the future Craves sweet, sour, salty Prefers moist environment Difficulty adjusting to temperature Love risk, and adventure Live in the present Craves bitter, sweet, astringent Prefers cool environment Competitive Love to stay at home Live in the past Craves pungent, bitter, astringent Prefers warm environmente Personality Creative, visionary Tendency toward fear/anxiety Aloof Spacey Spontaneous Sensitive Multitasking Fidgety Vigilant Emotions rollercoaster Bold, courageous Tendency toward anger volatility Detail-oriented Go-go-go Passionate Emotions controlled Influential/Domineering Critical/Judgmental Disciplined Lives in the head Affectionate Tendency toward lethargy/depression Calm, resilient Grounded/Stable Stubborn/Rigid Stable emotions Patient/Compassionate Loyal, dependable Smothering Unmotivated/Difficulty making changes Predictable Slow to react Brain and memory Good short-term, poor long-term memory; difficulty holding on to memories Wandering mind Difficulty making decisions Difficulty focusing Difficulty adjusting to temperature Understands easily Remembers details Easy to make decisions Focuses easily Mental acuity Good long-term, poor short-term memory Brain fog Can focus if it’s relatable Slow to understand Sleep Light sleep Wake easily Deep, but short sleep Wake feeling refreshed Deep, long sleep Waking is difficult Stress Fear/anxiety when stressed Need solitude when stressed Quick to anger when stressed Need action when stressed Despondency when stressed Need people when stressed Cardiovascular Tendency to be cold Tendency to be warm Tendency to be hot Rapid, erratic pulse Strong, bounding pulse Slow, steady pulse Low blood pressure High blood pressure Edema/swelling Anemia Stagnation/Poor circulation Digestive Variable appetite Strong, demanding hunger Predictable appetite Often forget to eat Think of food as fuel to keep going Feel good on only one or two meals a day Need to eat frequently Burning sensation after eating Eat to calm down Difficulty digesting heavy foods Strong digestion Feel heavy/stuck after eating Dry, pebbly stool Loose and regular stool Constipation Frequent gas Foul-smelling gas No gas Quick defecation after eating Yellowish/light brown stool NO time bowl movements Constipation or alternating constipation/diarrhea Diarrhea Difficulty holding on to nourishment Immune function Respiratory infections: scratchy throat, dry cough, body aches Respiratory infections: sore throat, fever, nausea Respiratory infections: congestion, runny nose, wet cough Complete exhaustion when ill Attempt to work through illness Take time off for hint of illness slow healing Recuperate quickly Recuperate slowly Hypo-immune function Spreading rashes Poor lymphatic circulation Poor immunity Easily inflamed Rarely ill Respiratory Respiratory tract easily irritated by dry air, smoke, or irritants Respiratory infections: easily irritated by hot environment Respiratory infections: easily irritated by cool/damp air Dry nasal passages Inflamed respiratory tract Nose/sinuses feel full/swollen Little mucus; mucus dark in color Frequent yellow or green mucus Frequent clear/white mucus Shallow and rapid breathing Infections settle in lungs Urinary Frequent urination Excessive thirst Infrequent thirst Urgent need to urinate when nervous Prone to bladder & kidney infections Urine often cloudy Frequently thirsty; fluids “run right through” Urine often yellow Urine often foul-smelling Infrequent urination; large volume Menstruation Menses irregular Menses regular, cycle may be on the short side Menses regular, cycle may be on the long side Premenstrual lower back pain and anxiety Premenstrual irritability Water retention before menses Brownish clots Heavy bleeding Menses start with brown blood/spotting Sharp, stabbing cramps, may start before blood Sharp, stabbing cramps during blood flow Pressing, dull, aching cramps Fatigue with menses Loose stool with menses Constipation before menses Amenorrhea Integumentary Skin is cool, dry, thin, flaky Skin is warm, oily, inflamed Menses regular, cycle may be on the long side Premenstrual lower back pain and anxiety Premenstrual irritability Water retention before menses Brownish clots Heavy bleeding Menses start with brown blood/spotting Sharp, stabbing cramps, may start before blood Sharp, stabbing cramps during blood flow Pressing, dull, aching cramps Fatigue with menses Loose stool with menses Constipation before menses Amenorrhea Send