Patient Questionnaire for Lee’s Oriental Health Foods

Name _____________________________ Date ____________________

Birthdate _____________________ Sex M ___ F ___

Height _________ Weight __________

Occupation ______________________________________________________________

Address ________________________________________________________________

E-mail ______________________________ Phone ______________________________

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Name and/or describe the condition or illness for which you are seeking help.

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History of this disease or condition (time of onset, severity, etc.) :

________________________________________________________________________

________________________________________________________________________

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Past injuries _____________________________________________________________

Past surgeries ____________________________________________________________

Family history (any diseases which pertain to your family, such as

heart disease, diabetes, cancer, etc.) __________________________________________

Current medications _______________________________________________________

Allergies (e.g. shellfish, etc.) _______________________________________________

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PERSONAL HEALTH PROFILE

(Please answer all questions to the best of your knowledge. While they may seem very detailed and personal, they are very important to the herbalist.)

Appetite (normal, very good, poor) ___________________________________________

Favorite season (are you a cold weather person or a hot weather person?) ________________________________________________________________________

Eating habits

Are you a meat eater? How much? ___________________________________________

Vegetarian? _____________________________________________________________

Vegan?_________________________________________________________________

Are you a snack eater?___________ How many times a day?______________________

What do you snack on? ____________________________________________________

Do you have a sweet tooth? _________________________________________________

How much do you drink during the day? What kind of drinks (soda, water, alcohol, etc)?

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Do you use mouthwash? _____ How many times a day? __________________________

When you wake in the morning, is your mouth bitter? Sticky? Describe.

_____________________________________________________ __________________

Do you smoke? How much? ________________________________________________

How much do you sweat? (average, above average, less than average) ______________ Where do you sweat the most (e.g. armpits, palms)?______________________________

Do you get headaches? ______ How often? ____________________________________

Where is the pain located on your head? _______________________________________

Describe the headache (dull, throbbing, splitting, heavy pressure, etc.) ________________________________________________________________________

Heartbeat? (normal or irregular?) ____________________________________________

Does your heart react to sudden happenings, loud noises, etc.? ________________________________________________________________________

Do you suffer from motion sickness? If so, how bad? ____________________________

Urine flow (normal? smooth?) _____________ If not, explain. _____________________

Any pain or problems with urinating? _________________________________________

Do you wake up in the night to urinate? How many times? ________________________

Are bowel movements regular? _____ irregular?______

Any constipation? ________ How many days? __________________________________

Is the movement hard at the beginning, then easy? _______________________________

Hard from beginning to end? ________________________________________________

Are stools well-formed, loose, small pellets, etc.? _______________________________

What is the color of your stool? ______________________________________________

How does your stool smell (normal, very bad, fishy, etc)? _________________________

Do you have hemorrhoids? __________ Are they very bad or bearable? ______________

Sleep Do you sleep well? __________________________________________________

Do your cover your feet while sleeping? _______________________________________

Are you a night owl or a morning person? _____________________________________

Do you dream at night? _______ Any nightmares? ______________________________

What kind of dreams? (sexual, dreams with people who have died, escape dreams, etc.) ________________________________________________________________________

Temperament How would you describe your temperament? (easygoing, irritable,

consistent, angry, moody, depressed)__________________________________________

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