Herbal Consultations Page

      First Name:       Last Name:

                Age:

          Address:

                City:       State:       Zip Code:

Phone Number: Use phone number to best be reached at.

E-Mail Address:

Employment Status:
Full Time    Part Time    Student    Retired     Unemployed     Other

    Occupation:

Marital Status:

Number of Children and their ages: Note: The Case history notes and medical information recorded during the consultation are kept strictly confidential and will be kept in a locked file cabinet in this office. Old documents will be appropiately disposed of, such as, use of a paper shredder. Information contained here will not be released to any person except when you have authorized me by filling out a signed release form from you allowing me to do so.

Please complete this questionnaire as thoroughly as possible.

Where did you hear about Cosmeos Natural Health and Beauty?

What are the health concerns that brought you here today?

When did this condition(s) begin?

Are you currently receiving care from any other Health Professional (Name)?

For what conditions?

Are you currently using Supplements and /or Medications?
Medication/Supplement/Herb Name: Potency/Frequency

Do you have any infectious diseases that you know of?  Yes   No
      If yes, please list:
     

Is there any chance that you are pregnant?  Yes   No

Nursing?  Yes   No

Do you have any allergies or sensitivities (drugs, pollens, foods, etc.)?

Can you take remedies made in alcohol? Yes   No

Have you had any operations or been in hospital for some other reason (date and reason)?

Accidents/Injuries (briefly describe):
   More than 5 years ago:
  

   Accident/Injuries less than 5 years ago:
  

Family Medial History
Please complete this section for any family members with particular health problems.

Father, Mother, Brothers/Sisters, Children, and other Blood Relatives
Age (if deceased, age of death).
Health Problem

Personal Health Habits

Height:     Current Weight:    Weight, 1 year ago:

Are you Current Smoker: Yes  No

   If yes, Cigarettes    Cigars    Pipe

   How many years:   Amount per day:

Have you smoked in the past? Yes   No

Do you use recreational drugs? Yes  No

   If yes, What     Frequency:

Do you exercise regularly? Yes  No

   If yes, Frequency:    Type:    

   Duration:

Diet
Do you drink alcohol? Yes  No

   If yes, What     Frequency:

Do you drink coffee? Yes  No

   If yes, how much:

Do you drink tea? Yes  No

   If yes, how much:

Do you drink water? Yes  No

   If yes, how much:

What do you like about your dietary habits and what would you like to change?

Do you now follow or have you ever followed a restricted diet? Please indicate when and describe the diet:

Health Concerns
Please check off if you have experienced any of these in the last 3 months:

Skin, Nails, and Hair
Rashes        Poor Healing Sores     Hives     Itching
Eczema        Pimples     Dandruff      Loss of Hair
Recent Moles     Change in texture     Varicose Veins
Any other problems with skin, nails and/or hair?

Head, Eyes, Ears, Nose, and Throat
Poor Vision     Cataracts     Glaucoma     Earaches
Blurred Vision     Poor Hearing     Ringing Ears     Sore Throat
Canker Sores     Cold Sores     Grinding Teeth     Nosebleeds
Facial Pain     Clicking Jaw     Eye Pain     Sinus Congestion
Mucous in Throat     Dizziness    Frequent Colds     Spots in front of your eyes
Swollen Glands
Any problem with your head?

Cardiovascular
High Blood Pressure     Low Blood Pressure     Chest Pain     Fainting
Irregular Heart Beat     Cold Hands or Feet     Ankle Swelling     Palpitations
Easy Bruising     Varicose Veins     Blood Clots     Breathing Difficulties
Any other problems with the heart or circulation?

What is your blood-pressure reading?

Gastro-Intestinal
Nausea     Vomiting     Diarrhea     Constipation
Black Stools     Bad Breath      Indigestion     Abdominal Pain
Heartburn     Gas     Blood in Stools     Mucous in Stools
Rectal Pain     Hemorrhoids     Bloating     Food Cravings
Poor Appetite     Gallstones     Ulcers     Difficulty Swallowing
Colitis/IBS     Liver Problems
Number of Bowel Movements per day:
Are they? Loose     Normal     Hard
Do the stools: Float      Sink     Have Bad Odor     No Odor     Have Blood in the Stool
Do you rely on any of the following for bowel elimination? Yes      No
   If yes, Enemas      Laxatives       Purgatives
   What type/brand:

             How often:
Any other digestive problems:

Respiratory
Cough     Bronchitis     Asthma     Coughing Blood
Pneumonia     Pain on Breathing     Shortness of Breath without exertion
Difficulty Breathing Lying Down Production of Phlegm If so, what color?
Any other Problems with Breathing?

Urinary
Pain on urination      Frequent Urination     Blood in Urine
Urgency of Urination     Kidney Stones     Irregular Flow
Impotency      Inabiltiy to Hold Urine     Decrease in Flow
Water Retention     Burning Urine     Difficulty Stopping or Starting
Prostrate Enlargement     Interstitial Cystitis
Any other Problems in Urination?

Musculoskeletal
Neck pain     Muscle Pain     Stiffness     Back Pain
Muscle Weakness     Broken Bones     Reduced range of Movement
Do you see a Chiropractor or Massage Therapist and what is their name?

Any other Musculoskeletal problems?

Reproductive
Age of First Period     Length of Cycle     Duration of Bleeding     Clotting
Light Flow     Color of Blood     Heavy Bleeding     Irregular Bleeding
Severe Menstrual Cramps     Discharge     Color of Discharge     Herpes
Cervical Dysplasia     Endometriosis     Uterine Cysts     Fibroids
Vaginal Itching     Anemia     Pelvic Inflammatory Disease     Infertility
Hot Flashes     Dry Vaginal Lining     Osteoporosis     ERT Therapy
Hysterectomy     Pain with Intercourse     Tubal Ligation     Mastectomy
Lumpectomy     Vaginal Infection if yes, what type and how long?
PMS if yes, list symptoms:
            

Menopausal Difficulties? List experiences and/or symptoms you are currently experiencing?
     

Breast Implants? No    Yes Any Problems, please list:
                                    

Date and result of last PAP:

Number of Pregnancies:

Number of Births:

Number of Miscarriages:

Number of Premature Births:

Number of Terminations:

Number of Tubular Pregnancies:

Contraceptive History: List the kind(s) of contraceptives you have used, and for how long.

Birth Control Pills:

IUD:

Condoms:

Diaphragm:

Rhythm:

Chemical Spermicides:

Any other gynecological problems?
   

Neuropsychological
Poor Sleep     Poor Memory     Numbness     Depression
Irritability     Anxiety     Seizures     Migraine
Headaches     High Stress Levels     Loss of Balance     Lack of Coordination
Difficulty Concentrating      Foggy or Spacey Feeling
Hours of Sleep per day:

List Stress Management Techniques:

Any other neuropsychological problems?

General
Fatigue     Fevers     Chills     Night Sweats
Excessive Thirst     Slow Metabolism     Sudden Energy Drops
Intolerance to Heat or Cold
Any other Health Concerns or Problems?

To the best of your knowledge, have you ever been exposed to pesticides, toxic chemicals, heavy metals,
radiation, or other toxins encountered beyond daily life?

Personal
How do you feel about the following areas of your life? Please rate the areas of your life (Choose from Excellent/Good/Fair/Poor) and make any comments you would like to.

Self: Excellent Good Fair Poor     Comments:

Work:   Excellent Good Fair Poor    Comments:

Spouse or Significant Other: Excellent Good Fair Poor     Comments:

Sex: Excellent Good Fair Poor     Comments:

Family/Personal Goals: Excellent Good Fair Poor     Comments:

Life Purpose: Excellent Good Fair Poor     Comments:

Current State of Emotions and Feelings
Please take a moment to answer the following questions:

Are you able to express your feelings and emotions?

Is there an excess of stress in your life?

Do you have tools or techniques to relieve stress?

Are you satisfied with your current environment?

If there is one thing in your life that you would like to change right now, what is it? Can you change it?

Are you a 'Nervous Type' person? What are the things, which make you the most nervous?

Do you sleep well? Yes No

What feelings do you most experience in your life? Joy, happiness, anger, sadness, fear, sympathy, worry, depression or maybe some other?

Vision Statement

What is your goal or achievement that you would most like to accomplish with this visit?

Ideally what state of health can you visualize achieving for yourself?

Waiver of Liability
By clicking on this checkbox, I hereby confirm that I am consulting with Stacey Williams of Cosmeos Natural Health & Beauty, of my own free will. I understand that there will be no diagnosis made, nor prescription given, but that the above named Master Herbalist will offer an assessment of my general health and will make dietary and herbal recommendations. I understand the importance of frequent monitoring to revise the suggested protocol as the symptom picture changes.