Herbal Medicine

Faculty-Supervised
Student Clinic

Instructions for your first herbal consultation

Thank you for giving thoughtful consideration as you complete the enclosed New Client Questionnaire. You will have ample
opportunity to address any concerns that require more detail during your appointment with your practitioner.

Required for your first visit:

• The completed New Client Questionnaire

Please also bring the following:

• Any labs, blood tests or other pertinent medical information you think may be helpful.
• If you are taking any pharmaceuticals, over-the-counter drugs, herbs, and/or supplements, please bring them in their
original containers so your practitioner can be sure to see what ingredients and amounts are in the products.

Client confidentiality will be observed under all circumstances.

If you do have any questions please contact your practitioner:

_______________________________________________________________________________

New Client Questionnaire Page 1

 Client confidentiality will be maintained at all times. The
HERBAL MEDICINE CLINIC information provided on this questionnaire may only be disclosed

New Client Questionnaire with the express written consent of the individual named herein
or, if under the age of 18, his or her legal guardian.

Please allow 30-45 minutes to complete this questionnaire. Please answer the questions below as thoroughly as possible so that we may make
the best possible clinical assessment and develop a realistic and workable plan for supporting you in reaching your health goals. Your
answers to personal questions such as relationship status, religion, etc. are important as they provide helpful context for establishing a
productive partnership with you. That said, please answer only the questions you are comfortable answering.

Today’s Date:

Basic Information
Contact Information
Name: Address:

Work phone: Home phone:

Mobile phone: Email:
Preferred contact Best time(s) of
method: day to reach you:
Emergency Contact
Name: Relationship: Phone:
Occupation & Interests
Occupation: How long? Satisfied?

What are your interests/passions:

Demographics
Age: Date of Birth: Gender: Race: Ethnicity:
Height: Weight: lbs Highest Adult Weight: lbs / Yr: Lowest Adult Weight: lbs / Yr:
Relationship Information
Status: Partner’s Name: Partner’s Gender:

Personal Information
Religion: Education:

With whom (persons or animals) do you share your home?

What types of health practitioners are you currently working with?

How did you hear about Tai Sophia’s clinic?

What are your primary reasons for coming to the Herbal Medicine clinic?
1.
2.
3.

New Client Questionnaire Page 2

Medical Information
What health concerns did you experience as a child?

What health concerns have you experienced as an adult?

Are you part of a recovery program? If so, which one?

Do you have any allergies to foods, medications, chemicals, and/or other environmental substances?
If so, to which ones?

What is your typical reaction and how severe is it?

What, if any, surgeries/operations have you undergone, and when?

Have you ever been hospitalized for reasons other than surgeries/operations?
If so, when and for what reason(s)?

Have you ever had a major chemical exposure? If so, when and to what?

Where and when have you lived or traveled outside of the U.S. and Canada?

Is there anything that surfaced during a recent medical test, lab work, or doctor’s visit that you would like to report?

Please place an “X” next to anything you are currently experiencing. Issues that you had previously, but no longer have, mark with a “P.”

Skin/Musculoskeletal Circulatory Nervous Men: BPH

rash bruise easily seizure Men: erectile insufficiency
acne varicose veins headache
changing moles swollen or painful lymph nodes migraines Other/Cross-Functional
slow wound healing insomnia eye problems
arthritis Urinary depression hearing loss
gout bladder infection anxiety ringing in the ears
kidney infection hair loss
Respiratory kidney stones Endocrine
difficulty breathing low blood sugar
Gastrointestinal high blood sugar/diabetes
Cardiovascular bloating
high blood pressure diarrhea Reproductive
low blood pressure constipation sexually transmitted disease
heart palpitations gas/flatulence Women: breast issues
rapid heartbeat hemorrhoids Women: vaginal discharge
high cholesterol nausea Women: yeast infections
stroke liver/gallbladder issues Women: abnormal pap smear

New Client Questionnaire Page 3

Review of Body Systems

Please indicate any of the following items that you are currently experiencing or that is relevant to your current health. Also provide
answers to those items marked with a question mark.

Head Female Reproductive Gastrointestinal Cardiovascular

seizure Breasts bad breath high blood pressure
headache tenderness mouth ulcers low blood pressure
migraines lumps bloating heart palpitations
Eyes discharge pain/cramping rapid heart beat
vision loss changes in shape gas chest pain
tearing perform breast self-exams? nausea high cholesterol
discharge abnormalities acid reflux/GERD varicose veins
redness mammograms (if applicable) constipation spider veins
pain Genitals diarrhea cold hands and feet
corrective lenses vaginal discharge undigested food in stools stroke
Ears redness blood in stools clotting tendency
hearing loss recurrent yeast infections ulcers Endocrine
ringing the ears STDs polyps low energy level
discharge pelvic pain or masses hemorrhoids hypothyroid (low)
itching painful intercourse/orgasm gall stones hyperthyroid (high)
history of infection low libido liver/gallbladder issues low blood sugar
Nose abnormal pap smear, Bowel movements diabetes
discharge resulting action? # per day? Skin
blood Menses # per week? rash
congestion age at onset of menses? quality? dry skin
Neck and Throat length of menstrual cycle? days pebbly itching
pain amount of bleeding? fully formed acne
lump light soft and largely unformed rosacea
enlarged thyroid moderate loose and unformed changing moles
stiffness heavy float or sink bruise easily
tonsillitis quality of bleeding? color? nail growth
Lymph Nodes bright red cardboard brown hair loss
congestion brown green hair quality changes
swollen clotting yellowish slow wound healing
painful painful cramps dark/black Musculoskeletal
infection bleeding between cycles Respiratory myalgia
drainage mood swings around cycle congestion arthritis
Male Reproductive absence of menstrual cycles sinus pain/inflammation stiffness
difficulty with urination birth control, difficulty breathing joint pain
BPH what form? cough gout
genital masses Menopausal women wheezing backache – upper/lower
penile discharge age of menopause ? tuberculosis mobility restrictions
prostate pain menopausal symptoms Urinary Neuropsychiatric
pain or swelling in testicles vaginal bleeding urinations per day? phobias
vasectomy vaginal dryness color of urine? stress
erectile insufficiency hormone replacement therapy history of bladder infection insomnia
painful intercourse/orgasm osteoporosis history of kidney infection depression
burning on ejaculation Allergic & Immunologic kidney stones anxiety
blood in semen respiratory allergies swelling of ankles or legs attention deficit
low sperm count frequent colds or flu incontinence mental sluggishness
poor sperm motility food allergies urgency shingles
low libido food sensitivities frequency other mental disorder
STDs immune disorder pain on urination abnormal physical
birth control, blood in urine movements
what form? lower back pain
dark circles under eyes

New Client Questionnaire Page 4

For Women:
Pregnancies (please include losses/terminations)
Year Vaginal/C Section Sex Complications/Other Things You Want to Mention

Are you currently pregnant? Are you actively trying to conceive?

Are you aware that you should inform your practitioner if you decide to conceive or if you become pregnant?

Family History
Relationship Alive/Deceased Present Health or Cause of Death
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Father
Mother
Brothers
Sisters
Children/ages

Medications & Supplements

Medications (Over-the-Counter and Prescription)
Name Dosage Frequency Length of Time Reason for Taking

Are you sensitive to low levels of medication(s) and/or caffeine?

Vitamins, Minerals or Herbal Supplements
Name Brand Dosage Frequency Length of Time Reason for Taking

New Client Questionnaire Page 5

Lifestyle
Diet
Food/Drink Frequency Comments
Never or Rarely Occasionally Regularly Most Days
(< 1x/Month) (< 1x/Week) (> 1x/Week) of the Week
Caffeine In what form?

Soda/Soft Drinks What type(s)?

Alcohol What type(s)?

Red Meat Beef, Lamb

White Meat Poultry, Pork
Eggs
Fish
Nuts & Seeds
Fruits Canned, Fresh, Frozen
Vegetables Canned, Fresh, Frozen
Plant Oils (e.g., olive) What type(s)?

Dairy Products Milk, Yogurt, Cheese, Butter

Soy Products
Bread & Other Grains What type(s)?

”Junk / Fast Food” What type(s)?

Fried Foods What type(s)?

How many times each week do you eat each meal at home (vs. out)? Breakfast, Lunch, Dinner
How many ounces of water do you drink per day? oz Bottled, Filtered, Tap
Lifestyle
Frequency Comments
Never or Rarely Occasionally Regularly Most Days
(< 1x/Month) (< 1x/Week) (> 1x/Week) of the Week
Exercise What type(s)?

Sexual Activity
Socializing w/Friends
Relaxation What type(s)?

Self-Pampering What type(s)?

Tobacco What type(s)?

Recreational Drugs What type(s)?

Sleep
At what time are you typically in bed?
What time do you fall asleep?
Typical hours asleep?
# of times you awaken during the night
Reason(s) why you wake during the night
Do you wake to an alarm clock?
Do you feel rested upon rising?

New Client Questionnaire Page 6

 Stress
On a scale of 1-10, with 1 being low and 10 being high, how stressful is your:
Work: Social/family situation: Current health status: Life in general:
Do you feel that your current state of health is: largely in your control or largely out of your control
What do you believe you can do to make a difference in your current health status?

If so, what 1-2 key steps have you already taken?

Moods You Experience Frequently

accepting anxious or nervous angry capable compassionate
determined dreadful empowered enthusiastic fortunate
guilty happy hopeful hurt inspired
lonely loved peaceful resentful resigned
sad scared terrified tired uncertain
other:

Significant Life Events

Please list major events in the last ten years of your life and the dates they occurred. Include births, deaths, marriage, divorce,
accidents, moves, jobs changes, miscarriages, illness, and anything else you feel greatly impacted your life.
Date Event

Constitutional Assessment
The following section provides us with an overview of your personal constitution, which is helpful information for determining
which herbs and nutritional guidance are most appropriate for you. For this reason, please evaluate yourself as accurately and
honestly as you can, based on how you have reacted in general throughout your lifetime, not how you react at present. Avoid
the temptation to see yourself as you would like to be rather than as you are. There is no right or wrong, and no better or worse,
in this assessment. There is only the reality of your personal constitution. Your answers may primarily appear in one column or
they may cross multiple columns.

New Client Questionnaire Page 7


Narrow shoulders, hips
Lose weight without difficulty, gain
weight with difficulty
Skin is cold to the touch (especially
hands and feet)
Skin is dry, or oily and dry
Sweat is scanty, even in heat
Hard and brittle
Variable appetite
Variable interest in food
Dizzy or faint without snacks
Defecate one-few times per wk
Stools often hard, dark-colored
Stools move with strain
Respond to laxatives
Irregular cycles
Scanty flow, sometimes clotting
Blood is dark in color
Constipation before period
Sharp, intense cramps
Energy comes in spurts/bursts; prefer
to expend it when avail.
Like vigorous exercise, but it
eventually exhausts
Difficult to fall asleep
Light or variable sleeper; difficult to
return to sleep when wakened
Rarely achieve adequate sleep
Rise feeling unrested
Talkative; speak quickly
Tendency to stray from subject
Sensitive
High strung/anxious
Rarely see project through
Friendships are often short-term
Theorist (idea-focused)
Remember and forget easily
Difficult to form habits
Thank you for taking the time to complete this questionnaire.
New Client Questionnaire
Body Frame & Weight
Medium shoulders, hips
Lose or gain weight without difficulty
Skin & Nails
Skin is warm to the touch
Skin is oily
Sweat is profuse, even in cold
Soft and strong
Appetite
Strong appetite
Enjoy eating
Irritable if meals are missed
Digestion & Evacuation
Defecate multiple times per day
Stools soft to loose, yellowish
Stools move easily
No need for laxatives
Menstruation
Regular, long length cycles
Heavy flow
Blood is bright red
Loose stools before period
Medium intensity cramps
Physical Strength and Endurance
Constant supply of energy; drive to
be active can cause overload
Like vigorous exercise and can
endure if paced well
Sleep
Easy to fall asleep unless worried
Light sleeper; returns to sleep easily
when wakened
Get by on minimal sleep
Rise feeling alert
Voice
Concise and direct in speaking
Speaking is purposeful
Personality Traits
Strong and forceful
Domineering/opinionated
See projects through
Friendships serve a purpose
Mind
Planner (design-focused)
Memory
Remember easily and forget with
difficulty
Lifestyle
Make or break habits easily
Broad shoulders, hips
Lose weight with difficulty, gain weight
without difficulty
Skin is cool to the touch
Skin is moist and supple
Sweat is moderate, consistent
Thick and strong
Moderate appetite
Moderate interest in food; at times prone
to emotional eating
Can miss meals without any physical
distress
Defecate once daily
Stools well-formed, rarely hard, medium
brown-colored
Stools move slowly
Respond only to strong laxatives
Regular, average length cycles
Moderate flow
Blood is light in color
Prone to water retention
Dull, achy cramps
Prefer not to expend energy, but feel good
with regular activity
Endure vigorous exercise well, but prefer
not to partake
Easy and quick to fall asleep
Sleep soundly throughout the night; rarely
wakened
Prefer many hours of sleep
Rise feeling rested and alert
Talk when there’s something to say
Speaking is slow and cautious
Calm and quiet
Patient/compassionate
See projects through stubbornly
Friendships are often long-term
Implementer (process-focused)
Must be told something more than once to
remember, but then it sticks
Enjoy habits
Page 8