Chinese Herbs For People. Herbal Remedies & Natural Supplements for People

Traditional Chinese Medicine Questionnaire

1.) Energy level:

10=Excellent, 1=Poor

2.) Head:

I am pale

I have a red flushed complexion

My chest has a red flush to it

I get headaches

3.) The climate seems to make my condition worse when:

Comment:

Step: 2 of 5

4.) Sleep:

Trouble falling asleep	Trouble staying asleep
I wake in the middle of the night	I have vivid dreams
I sleep more than 10 hours a day	I take sleep medications
I feel anxiety when I try to sleep

5.) Subjective Body Temperature:

I have night sweats	I feel warm most of the day
I use multiple blankets when I sleep	I prefer to wear sweaters
Heat makes me feel tired	My hands and feet are always colder than the rest of my body
I feel chilled most of the time

6.) Appetite/Thirst:

7.) Digestion:

Comment:

Step: 3 of 5

8.) Elimination:

Frequent daytime urination	Frequent nighttime urination
Clear profuse urination	Dark/ pungent smelling urination
Known Prostate problems

9.) Skin & Nails:

10.) Eyes:

11.) Ears:

12.) Lungs:

Asthma

Worse with inhalation

Worse with exhale

Chronic cough

Wet	Dry
Allergy related	Flu related

I have lots of phlegm

I smoke

13.) Nose:

14.) What season worsens your condition?:

Comment:

Step: 4 of 5

15.) Emotions:

16.) Pain:

When did the pain start?

Does anything make it better?

Does anything make it worse?

Comment:

Step: 5 of 5 - Please tell us your information

Client Name:				Age:		Sex:
Severity:	(10=Very Severe)					Weight:

What is your main compliant today?

How long has it been a problem?

List all medications and supplements you are taking:

List all herbs that you are taking?

What medical diagnoses have you received?

Review of systems:

Do you have high blood pressure?

Do you have any problems with your Heart?

Do you have problems with your Liver?

Do you have problems with your Kidneys?

Do you have neurological problems?

Please tell us your contact information

First Name:

Last Name:

Email Address:

Retype Email Address:

Phone #:

Cell/Nightime Tel #:

Best Time to Call:

Prefer Phone call or Email:

By Phone

By Email

Have you ever worked with herbs before?

Please tell us what questions or concerns you may have so that we may help you purchase one of our formulas:

What is your state? We would like to know where you are located to be able to call you at the right time:

If other please tell us where other is:

Final comments: Please tell us anything you feel that has not been asked:

How did you find us?
If other please tell us who other is:

People Healer

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