Master Herbalist Questionaire

Date:
Name:
Age:		Birthdate:

Address:

Home Phone:	Work Phone:

Email:

Height: Weight: 1 year ago: 5 years ago:

Occupation:

Part Time Full Time Other

What's your living situation?

Alone Friends Partner Spouse Parents Children Pets

What are your major health concerns and intentions for your visit today?

Please list any other health care providers or consultants you are currently working with:

Please list any current health conditions diagnosed by a medical doctor:

When was your last physical exam?

Please list all herbs, vitamins, and dietary supplements you are currently taking, including dosage and frequency:

List all medications you are currently taking (including aspirin, antacids, etc.) indicating whether they are over the counter (OTC) or Prescription, including dosage and frequency:

List all medications, herbs, foods, environmental factors, to which you have a known, allergy:

DIETARY INFORMATION

Describe below your typical meals. Please be as specific as possible. For example, instead of “oil” note type of oil, such as olive, corn, etc. Instead of ‘’bread” list whether white or whole grain, etc. Instead of “vegetables” list the type of vegetable, how prepared, canned, frozen, or fresh, etc. Please include all beverages, type and quantity (two cups of orange juice, one cup of coffee, etc.)

Breakfast

Morning snack(s)

Lunch:

Afternoon Snack(s)

Dinner

Night time Snack(s)

Daily water consumption:

Any recurring food cravings (such as salt, starch, sugar, chocolate, etc.) please list as many as applicable including time of day or month:

FAMILY HISTORY

Please describe any relevant or major health related issues: (cancer, mental illness, Diabetes, heart disease, etc.)

Mother:

Father:

Sister(s)

Brother(s)

Maternal Grandmother:

Maternal Grandfather:

Paternal Grandmother:

Paternal Grandfather:

MEDICAL HISTORY

List all major health problems including any operations:

PROBLEM YEAR

GENERAL HEALTH

Cardiovascular Skin Muscles/Joints

High blood pressure	Boils	Backache
Low blood pressure	Bruises	Broken Bones
Pain in Heart	Dryness	Limited mobility
Poor Circulation	Itching	Arthritis
Swelling	Varicose Veins	Bursitis
Stroke/Murmur	Skin Erruptions	Weakness

Respiratory Urinary/Kidney Gastro-Intestinal

Chest Pain	Excessive Urnination	Belching
Difficulty breathing	Water Retention	Colitis
Cough	Burning Urine	Constipation
Tuberculosis	Kidney Stones	Abdominal Pain
Congestion	Lower Back Pain	Liver Disorders
Itchy Ears/Eyes	Wheezing	Gallstones
Asthma	Circles under eyes	Ulcers
Coughing up Blood	Blood in Urine	Digestive Troubles

Eyes, Ears, Nose and Throat

Ear aches	Eye pains	Failing vision
Hay Fever	Sinus Infection	Sinus Congestion
Sore Throat	Tonsils	Hearing Loss
Canker Sores	Nose Bleeds	Difficulty Breathing

General

Fatigue	Night Sweats	Fever
Excessive Thirst	Loss of apetite	Always Hungry
Difficulty Sleeping	Irritability	Cold hands and feet

Male Reproductive

Burning/Discharge	Lumps/Swelling of Testicles	Painful testicles
Vasectomy

Female Reproductive

Age at first period:

Irregular Cycles	Pre-menopausal	Heavy bleeding
Blood clots	Menopause	Vaginal Discharge
Vaginal itching	Cramps/Pain	Painful intercourse
Vaginal Dryness	Pelvic Pain	Breast Pain
Breast Lumps	Anemia	Infertility
Genital Herpes	Hot Flashes	Mood Swings
PMS	Not able to Conceive

Contraceptive/Pregnacy History

Birth Control Pills	Rythm Method	I.U.D
Diaphragm	Condoms	Mucus Method
Cervical Cap	Spermicides	Fertility Lens

Please list each pregnancy you have had, including miscarriages:

CURRENT STATE OF EMOTIONS AND SPIRITUAL WELL-BEING

I am often not able to express my emotions.

I am dissatisfied with my job.

I am often stressed out and not able to cope properly.

Even though I’m in a relationship, I often feel lonely.

I often feel anxious and nervous for no good reason.

I don’t sleep well at night and have a hard time waking up in the morning.

I often suffer from bad dreams and nightmares.

There are many things I’d like to change in my life I just don’t have the means.

I have very low energy and often feel exhausted mentally and physically.

I don’t enjoy my work and would rather be doing something else.

I find my children irritating and hard to relate to.

I have very few hobbies.

I often feel depressed for no reason.

I often become angry with people and feel guilty about it later

I have a hard time letting go of the past.

I don’t look towards the future with much enthusiasm.

I am not able to concentrate for extended periods of time.

My outlook is more negative than positive.

I spend a great deal of time worrying about what people think about me

I tend to see the good in people.

I have a great sense of humor and love a good joke

I receive great joy from my family.

My outlook on life is positive.

My job uses all my greatest talent.

I have plenty of energy to do all the things I want.

I sleep well at night and feel rested in the morning.

I can concentrate on the task at hand for as long as it takes

I have a strong spiritual faith.

I am able to express anger constructively

I practice meditation or other relaxation techniques.

I try to maintain peace of mind and tranquility

I have many close friends that I can always count on.

I accept full responsibility for my actions.

I trust my intuition and believe that things happen for a reason.

I do not harbor any resentment from the past.

I can feel completely fulfilled even if I’m alone

I have many hobbies and interests to keep me preoccupied.

How I see myself is more important than how others see me.

I often go out of my way to help others.

Please list approximate dates and describe the nature of any traumatic experiences you have had in the past 7 years (divorce, surgery, end of a relationship, loss of job, change of residence, injury, death of a loved one, etc.)

Year/Event:

LIFE STYLE HABITS

Do you engage in regular physical activity? Yes No

If Yes, for how many minutes?

How often?

Do you smoke tobacco? Yes No

If Yes, how much per day?

Do you drink Alcohol? Yes No

If Yes, how much?

How often?

Do you drink coffee and/or other caffinated beverages? Yes No

If yes, How much?

How often?

How many hours of televison do you watch a week?

Please use this space to add any other information about yourself that you think will be helpful to us: