Herbal Consultation Client Intake Form

Banyan Moon Botanicals Referred by: College Station, TX 803.443.8246 Reason for Visit: www.banyanmoonbotanicals.com [email protected] Kristin Henningsen, M.S., C.H., R.Y.T. Primary complaints and symptoms:

Other Problems:

Herbal Consultation Client Intake Form Daily physical activity level (circle

one): light /moderate /heavy

Name Daily / Weekly Exercise:

Mailing Address Are you currently under the care of a health care practitioner? Please note Phone which of the following types of practitioners you have seen. Use “P” Email to indicate in the past and “C” to indicate if you are currently under Please Read: This is a rather long and their care. intensive form; please feel welcome to answer only the questions you feel ___ Medical Doctor comfortable with. You may skip any ___ Aromatherapist portions that you feel are not relevant to ___ Ayurvedic Practitioner you. ___ Chiropractor ___ Counseling ___ Herbalist How/when do you prefer to be ___ Homeopath ___ Naturopath contacted? ___ Social Worker ___ Massage Therapist ___ Occupational Therapist Age: ___ Other Bodywork ___ Physical Therapist Birth date: ___ Traditional Chinese Medicine Practitioner Gender: ___ Traditional Thai Massage Therapist Height: ___ Other (Please indicate) ______Weight: Western Medical Diagnosis (if known): Occupation: ____Arthritis ____Numbness ____Stiffness ____Diarrhea Other Diagnosis: ____Asthma ____Respiratory ____Dizziness problems ____Sore throats ____Chronic ____Alcoholism fatigue List any current medications and ____Drug abuse ____Common cold ____Diabetes treatments: Childhood diseases and syndromes Please check any pertinent to you ____Chicken pox ____Tonsilitis List any previous medications and ____Measles ____ADD ____German ____Bronchitis treatments: measles (Rubella) ____Mononucleosi ____Rheumatic s fever ____Whooping ____Asthma cough (Pertussis) Please check any of the below ____Allergies ____Mumps symptoms or diseases you have ____Atopic ____Learning experienced. Use a scale of 1-5, 1 being eczema disabilities infrequent to 5 being the most severe. If unsure, use a question mark ‘?’. Skin Mark any of the conditions below that ____Allergies ____Eyesight pertain to you. Use ‘P’ for past ____Headaches problems problem and ‘C’ for current. ____Bloating ____Hearing ____Sore throat problems ____Bruise easily ____Rashes ____Too hot ____Shortness of ____Dry hair ____Scars ____Too cold breath ____Dry skin ____Sensitive to ____Excess stress ____Rashes ____Eczema/psori chemicals ____Anxiety ____Chemical asis ____Sensitive to ____Fatigue sensitivities ____Hair loss touch ____Sleep ____Environmenta ____Itchy ____Skin tags problems l sensitivities ____Oily hair ____Slow to heal ____Night sweats ____High blood ____Oily skin ____Varicose veins ____Injuries pressure ____Pimples ____Seizures ____Low blood ____Immune pressure Energy Levels Disorders ____Stomach Time of day you feel most tired? ____Cancer aches ____Gynecological ____Constipation Time of day you feel most awake? problems ____Heart disease ____Menstrual ____Tumors Are you satisfied with your energy irregularities ____Male health ____Urinary tract problems level? infections ____Memory loss ____Painful joints Have you noticed your energy levels Has anyone in your family had any of the following? change dramatically at any point ___ Cancer recently or in your past? ___ Diabetes If yes, please describe: ___ Heart Disease ___ High Blood Pressure

Hospitalization ___ Low Blood Pressure Were you ever hospitalized? Allergies Reason: Do you have any allergies? Caused By? Treatment: Have or do you take any medicine for

Please list any surgeries you have had them? with approximate dates and reasons When and where are your allergies for them: least and most troublesome?

Are you allergic to any drugs Injuries (including herbal medicines)? Have you had any severe injuries? What has helped your allergies most? What therapies did you use for them?

Have you ever had broken bones?

Have you ever been in an accident? If Diet Please fill in the below chart using the yes, please describe following scale. O – Do not consume this Have you ever injured your spine or D – Consume this once a day FD – Consume this a few times daily back? W – Consume this approximately once a week FW – Consume this a few times Family History weekly M – Consume this approximately once Any history of illness in your family? a month

____Vegetables ____Vegetables cooked raw ____Vegetables ____Bread Please indicate any diets you are canned Products currently on or previously have been ____Fruit – fresh ____Refined flour on: or frozen ____Whole grains ____Fruit – ____Organic foods canned ____Black tea Digestion ____Fried foods ____Green tea Please use ‘P’ for previously, ‘C’ for ____Beef ____Coffee currently or ‘?’ for unsure. ____Chicken ____Herbal tea ____Pork ____Fruit Juice ____Fish ____Vegetable ____Anorexia ____Low appetite ____Other meat Juice nervosa ____Nausea (Indicate) ____Water ____Belching ____Pain after ____Seafood ____Soda ____Bulimia eating ____Seaweed ____Eat out ____Changes in ____Parasites ____Sweets ____Fast food bowel habits ____Scanty ____Potato chips ____Fasting ____Constipation appetite ____Tortilla chips ____Nuts/seeds ____Diarrhea ____Soy ____Eggs ____Peanut butter ____Diverticulitis Intolerance ____Milk ____Nut butters ____Eating ____Stomach ____Cheese ____Fermented disorders aches ____Pizza foods ____Flatulence ____Sudden ____Refined sugar ____Diet soda ____Food is weight change ____Unrefined ____Sweet & Low, unappetizing ____Trouble sugar Equal or other ____Gallstones digesting ____Baked goods Sugar ____Heartburn carbohydrates ____Hemorrhoids ____Trouble ____Indigestion digesting fats Describe your eating habits. Give ____Irritable ____Trouble examples of daily food intake. Bowel Syndrome digesting proteins Breakfast: ____Lactose ____Ulcer Intolerance ____Ulcerative Lunch: ____Large colitis appetite ____Vomiting ____Liver ____Wheat / Dinner: problems Gluten Allergy

Body Temperature Snacks: Please write ‘H’ for Hot and ‘C’ for Cold, if applicable to these body areas ____General body ____Feet Cravings (Circle all that apply) Sour ____Arms ____Head Sweet Salty Oily Bitter Bland ____Hands ____Back Describe your ____Palms ____Chest caffeine/nicotine/alcohol/drug intake ____Fingers ____Stomach ____Legs You tend to enjoy (circle one) hot cold Does the prescription of your glasses weather change often? Best time of year (circle all that apply) Ears spring summer fall winter How is your hearing? What part of the day are you the Has it changed in the past years? warmest? Have you previously had (P) or What part of the day are you the currently have (C) ____Earaches coldest? ____Hearing loss Do you sweat easily? ____Tinnitus/Ringing ____Overly sensitive ____Ear infections Emotional State ____Wax build-up Use a scale of 1 (rare) to 5 (very common) on the below conditions thatMouth & Throat are pertinent to you. Please list ‘P’ for previous or ‘C’ for current conditions ____Happy ____Forgetful ____Sore gums ____Multiple ____Enthusiastic ____Attentive ____Mouth sores cavities ____Inspired ____Grumpy ____Lip sores ____Loose teeth ____Sad ____Fearful ____Constant ____Oral herpes ____Depressed ____Angry dryness ____Sore throats ____Lethargic ____Nervous ____Difficult to ____Swollen ____Manic ____Worry swallow glands ____Bi-polar ____Excess saliva ____Swollen ____Anxious ____Painful/tight tongue Memory jaw How is your long-term memory? How is your short-term memory? Headaches Has your memory changed noticeably Do you ever have headaches? in the past few years? How often?

Eyesight Location/type of headaches How would you describe your vision? ____Migraine ____Band around Are you near or far sighted? ____Chronic head ____Cluster ____Back of head Do you wear glasses or contact ____Morning ____Base of neck lenses? ____Afternoon ____Around ____Evening temples At what age did you begin wearing ____Night ____Left side them? ____After eating ____Right side ____Before eating ____Sharp ____Around eyes ____Dull ____Throbbing ____Pounding ____Light but constant Approximately how many times a day do you urinate? Are they seasonal? If so, which Do you wake up at night to urinate? If season? Yes, How many times After a bowel movement, do they get Is it ever hard to urinate? better or worse? When you have the need to urinate, Other symptoms and troubles does it feel urgent? associated with the headache? Have you had urinary tract infections? Are they more or less often than in If Yes, how often? the past? How did you treat it? Are they related to your menstrual Bowel Movements cycle? Before, During or After (Circle How many times a day do you One) defecate? How long have you had them? Is it ever difficult to defecate? Does the severity or intensity vary Do your feces tend toward loose (soft) from episode to episode? or hard? What medicines and treatments have Are you ever constipated (not you tried? defecating for more than one day in a Which medicines and treatments were row)? the most successful? Do you ever have diarrhea (constant Do you have any ideas on what very loose stools)? triggers them? Is your urge to defecate urgent? Do you wake up at night or very early Urinary Tract Please mark ‘P’ for previous and ‘C’ morning to defecate? for current for any of the below Does it ever hurt to defecate? conditions ____Bloating ____Pain around Are your stools very strong smelling ____Blood in urine Kidneys often? ____Burning ____Strong urination smelling urine Do you strain to defecate? ____Frequent ____Urinary tract Other bowel problems or symptoms urges to urinate infections ____Kidney/Bladd ____Water er stones retention ____Lower back pain Reproductive – Male Use ‘P’ for past condition, ‘C’ for current, ‘S’ for unsure or ‘?’ for any questions. Reproductive – Female ____Frequent ____Low vitality Use ‘P’ for past condition, ‘C’ for urination ____Benign current, ‘S’ for unsure or ‘?’ for any ____Difficulty Prostatic questions. getting urine Hyperplasia (BPH) General Menopause flowing ____Prostate pain ____Breast pain ____Hot flashes ____Painful to ____Penis pain ____Endometriosis ____Night sweats urinate ____Testicle pain ____Cervical ____Hormone ____Interrupted ____Painful dysplasia replacement flow of urine ejaculation ____Fibroids therapy ____Erectile ____Blood in urine ____Unusual PAP ____Mood swings dysfunction ____Blood in ____Painful ____Other ____Impotence semen intercourse changes Other ____Vaginal Contraception How often do you get up at night to dryness Method ____Vaginal ____Birth control urinate? discharge pills Do you need to urinate frequently? Menstrual Cycle ____IUD ____Bleeding ____Diaphragm Approximately how often? between cycles ____Rhythm Do you drink coffee, black or green ____Mood swings ____Mucus testing ____Bloating ____Cycle Beads™ tea, or soda? (hands, stomach) ____Other (please Does your prostate region ever hurt? ____Bloating (feet,explain) hands, ankles) Other If yes, is pain dull, constant, ____Irregular ____Vaginal throbbing or sharp; while sitting, or cycle infection ____Painful ____Pelvic standing (circle) menses inflammatory Is it ever difficult to get your urine Does your blood disease (PID) tend to be? ____Tumors flowing? ____Bright red ____Infertility Is it ever painful to urinate – describe ____Red ____STDs ____Red brown ____Miscarriage the pain? ____Dark colored ____Ovarian or Does the urge to urinate interfere with____Clots other cysts your daily activities? Menses cycle >28 days Do you have any problems getting (Approx # of days______) Menses cycle <28 days and/or maintaining an erection? (Approx # of days______) Are you satisfied with your sexual Do you have pre-menses diarrhea/constipation? vitality? Average # of days bleeding______Do you have any health concerns ____Profuse flow ____Slow flowing about your sexuality or vitality? ____Scanty flow Which are your favorite hours to ____Heavy flow sleep? ____Dry vaginal mucosa ____Osteoporosis Generally, how many hours of sleep ____Fibromyalgia do you need to feel rested? Immune System What time do you generally get up in Please mark 0 for never, 1 for sometimes, 2 for almost always the morning? ____Allergies ____Chronically Do you feel you are getting the sleep ____Autoimmune sick disorders ____Heal slowly you need? ____Cancer ____Low grade ____Chronic fever diarrhea ____Lowered Cardiovascular Health ____Chronic resistance If known, what is your: fatigue ____Recurring Resting pulse rate Blood pressure ____Chronic sore infections throats ____Swollen (avg) Cholesterol level: lymph glands Does your blood pressure fluctuate Other comments on your immunity? much? Sleep Patterns Do you or have you taken any heart On a scale from 1 (rarely) to 5 (very often) mark the conditions pertinent medicines, including herbs, drugs or to you. others? ____Fall asleep fast ____Sleep through the night What are they? ____Hard to fall asleep, but stay Do you ever feel tight pains in your asleep throughout the night ____Hard to fall and stay asleep chest? ____Wake often When have they occurred? ____Wake up to urinate ____Restless sleep ____Restful sleep Please check the below questions ____Hard to wake up in the morning pertinent to your health ____Stay awake till 11:00pm ____Angina ____Cardiac arrest ____Stay awake till 1:00am ____Arrhythmias ____Chest pains ____Stay awake till 3:00am (irregular heart ____Congenital beat) deformities Dreams (circle those that apply): ____Arteriosclerosi____Congestive s heart failure active, lucid, anxious, nightmares, ____Black and ____Edema probing, pleasant, sexual, interesting, blue easily (swollen with ____Bleed easily water) scary, other ____Capillary ____Fast heart (describe______) fragility beat (tachycardia) (blood vessels ____Heart attack rupture easily) (myocardial ____Palpitation Is the quality and/or color of the infarction) ____Poor mucous: ____Heart circulation ____clear flutter/fibrillation ____Rheumatic ____yellow ____Heart murmurfever ____green ____High blood ____Slow heart ____thin/runny pressure beat (bradycardia) ____medium ____Low blood ____Stroke worse in the: pressure morning, afternoon,evening, night ____Mitral valve (circle one ) prolapse other______Which season brings the most congestion? Nervous System and Stress Have you identified foods, Please mark with ‘P’ for previously and ‘C’ currently to any conditions environmental factors, situations that are pertinent to you. which worsen your breathing (i.e. Please also follow a scale of 1 (not frequent) to 5 (chronic). with mucous/congestion or ____Anxiousness ____Nervousness tightness)? What are they? ____Nervous ____Numbness stomach ____Pain – Have you ever used a Neti Pot? ____Trouble fallingconstant asleep ____Pain – moves Coughing ____Cannot stay around body Check the symptoms which pertain to asleep ____Pain – sudden you ____Constant and soon gone ____frequently ____painful feeling of stress ____Panic attacks ____persistent ____bring up ____Difficult to ____Seasonal ____dry cough blood grasp small objectsaffective disorder ____wet cough ____infrequently, ____Diminished (S.A.D) ____abrupt onset ____worse at taste ____Sudden ____itchy at back morning, ____Fear of knownchanges in body of throat ____hacking ____Fear of temperature ____once started, unknown ____Sudden mood hard to stop ____Fluctuating swings What triggers your coughing? vision ____Twitching/Sha ____Hard to king concentrate ____Worsening Is it related to any other troubles in ____Involuntary coordination spasms ____Work related your body (i.e. headaches, stiff joints, ____Memory loss stress level high etc)? ____Nervous to answer the phone Which seasons are worse? Do you frequently have a cold or the Respiratory Do you have much congestion? flu? Please mark with a ‘P’ for previously a problem, ‘C’ for currently so, and ‘?’ if Disclaimer: This information is provided unsure. for educational purposes and is not ____Asthma ____Laryngitis intended as and must not be taken as a ____Bronchitis ____Runny nose diagnosis for any disease. ____Chest pain ____Shortness of ____Common cold breath ____Coughing ____Sneezing ____Difficulty ____Stuffy nose smelling ____Tight feeling ____Flu in chest ____Fluid in lungs ____Trouble ____Hay fever breathing ____Inflammation of lungs or bronchi Additional Questions & Notes

By filling out this questionnaire you are providing information to be used by Kristin Henningsen to assist you in creating a holistic lifestyle program. This information will not be used by any third party for any reason and will be kept strictly confidential. The questionnaire and follow-up consultation are not meant to substitute for a primary medical diagnosis or seeing a primary care physician or for treating, a serious or life-threatening conditions that should be seen by a qualified primary care medical doctor.

I have read & understand the above,

Sign______Date______