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 Send