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
HERBAL MEDICINE CLINIC
New Client Questionnaire
Client confidentiality will be maintained at all times. The
information provided on this questionnaire may only be disclosed
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
Address:
Name:
Work phone:
Mobile phone:
Preferred contact
method:
Home phone:
Email:
Best time(s) of
day to reach you:
Emergency Contact
Relationship:
Occupation & Interests
How long?
Name:
Occupation:
Phone:
Satisfied?
What are your interests/passions:
Status:
Demographics
Gender:
Race:
lbs Highest Adult Weight:
lbs / Yr:
Relationship Information
Partner’s Name:
Religion:
Education:
Age:
Height:
Date of Birth:
Weight:
Ethnicity:
Lowest Adult Weight:
lbs / Yr:
Partner’s Gender:
Personal Information
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 Bryan Bowen?
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
rash
acne
changing moles
slow wound healing
arthritis
gout
Respiratory
difficulty breathing
Cardiovascular
high blood pressure
low blood pressure
heart palpitations
rapid heartbeat
high cholesterol
stroke
New Client Questionnaire
Circulatory
Nervous
bruise easily
seizure
varicose veins
headache
swollen or painful lymph nodes
migraines
insomnia
Urinary
depression
bladder infection
anxiety
kidney infection
kidney stones
Endocrine
low blood sugar
Gastrointestinal
high blood sugar/diabetes
bloating
diarrhea
Reproductive
constipation
sexually transmitted disease
gas/flatulence
Women: breast issues
hemorrhoids
Women: vaginal discharge
nausea
Women: yeast infections
liver/gallbladder issues
Women: abnormal pap smear
Men: BPH
Men: erectile insufficiency
Other/Cross-Functional
eye problems
hearing loss
ringing in the ears
hair loss
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
seizure
headache
migraines
Eyes
vision loss
tearing
discharge
redness
pain
corrective lenses
Ears
hearing loss
ringing the ears
discharge
itching
history of infection
Nose
discharge
blood
congestion
Neck and Throat
pain
lump
enlarged thyroid
stiffness
tonsillitis
Lymph Nodes
congestion
swollen
painful
infection
drainage
Male Reproductive
difficulty with urination
BPH
genital masses
penile discharge
prostate pain
pain or swelling in testicles
vasectomy
erectile insufficiency
painful intercourse/orgasm
burning on ejaculation
blood in semen
low sperm count
poor sperm motility
low libido
STDs
birth control,
what form?
New Client Questionnaire
Female Reproductive
Breasts
tenderness
lumps
discharge
changes in shape
perform breast self-exams?
abnormalities
mammograms (if applicable)
Genitals
vaginal discharge
redness
recurrent yeast infections
STDs
pelvic pain or masses
painful intercourse/orgasm
low libido
abnormal pap smear,
resulting action?
Menses
age at onset of menses?
length of menstrual cycle? days
amount of bleeding?
light
moderate
heavy
quality of bleeding?
bright red
brown
clotting
painful cramps
bleeding between cycles
mood swings around cycle
absence of menstrual cycles
birth control,
what form?
Menopausal women
age of menopause ?
menopausal symptoms
vaginal bleeding
vaginal dryness
hormone replacement therapy
osteoporosis
Allergic & Immunologic
respiratory allergies
frequent colds or flu
food allergies
food sensitivities
immune disorder
Gastrointestinal
bad breath
mouth ulcers
bloating
pain/cramping
gas
nausea
acid reflux/GERD
constipation
diarrhea
undigested food in stools
blood in stools
ulcers
polyps
hemorrhoids
gall stones
liver/gallbladder issues
Bowel movements
# per day?
# per week?
quality?
pebbly
fully formed
soft and largely unformed
loose and unformed
float or
sink
color?
cardboard brown
green
yellowish
dark/black
Respiratory
congestion
sinus pain/inflammation
difficulty breathing
cough
wheezing
tuberculosis
Urinary
urinations per day?
color of urine?
history of bladder infection
history of kidney infection
kidney stones
swelling of ankles or legs
incontinence
urgency
frequency
pain on urination
blood in urine
lower back pain
dark circles under eyes
Cardiovascular
high blood pressure
low blood pressure
heart palpitations
rapid heart beat
chest pain
high cholesterol
varicose veins
spider veins
cold hands and feet
stroke
clotting tendency
Endocrine
low energy level
hypothyroid (low)
hyperthyroid (high)
low blood sugar
diabetes
Skin
rash
dry skin
itching
acne
rosacea
changing moles
bruise easily
nail growth
hair loss
hair quality changes
slow wound healing
Musculoskeletal
myalgia
arthritis
stiffness
joint pain
gout
backache – upper/lower
mobility restrictions
Neuropsychiatric
phobias
stress
insomnia
depression
anxiety
attention deficit
mental sluggishness
shingles
other mental disorder
abnormal physical
movements
Page 4
For Women:
Year
Pregnancies (please include losses/terminations)
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
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Father
Mother
Brothers
Sisters
Children/ages
Alive/Deceased
Present Health or Cause of Death
Medications & Supplements
Medications (Over-the-Counter and Prescription)
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
Name
New Client Questionnaire
Page 5
Lifestyle
Food/Drink
Never or Rarely
(< 1x/Month)
Diet
Frequency
Occasionally
Regularly
(< 1x/Week)
(> 1x/Week)
Comments
Most Days
of the Week
Caffeine
In what form?
Soda/Soft Drinks
What type(s)?
Alcohol
What type(s)?
Red Meat
White Meat
Eggs
Fish
Nuts & Seeds
Fruits
Vegetables
Plant Oils (e.g., olive)
Beef,
Lamb
Poultry,
Pork
Canned,
Fresh,
Canned,
Fresh,
What type(s)?
Dairy Products
Soy Products
Bread & Other Grains
Milk,
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)?
How many ounces of water do you drink per day?
Lifestyle
Frequency
Never or Rarely
Occasionally
Regularly
(< 1x/Month)
(< 1x/Week)
(> 1x/Week)
Exercise
Yogurt,
Breakfast,
Lunch,
oz
Bottled,
Filtered,
Frozen
Frozen
Cheese,
Butter
Dinner
Tap
Comments
Most Days
of the Week
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?
accepting
determined
guilty
lonely
sad
other:
anxious or nervous
dreadful
happy
loved
scared
Moods You Experience Frequently
angry
empowered
hopeful
peaceful
terrified
capable
enthusiastic
hurt
resentful
tired
compassionate
fortunate
inspired
resigned
uncertain
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
Body Frame & Weight
Medium shoulders, hips
Lose or gain weight without difficulty
Skin & Nails
Skin is warm to the touch
Variable appetite
Variable interest in food
Skin is oily
Sweat is profuse, even in cold
Soft and strong
Appetite
Strong appetite
Enjoy eating
Dizzy or faint without snacks
Irritable if meals are missed
Defecate one-few times per wk
Stools often hard, dark-colored
Digestion & Evacuation
Defecate multiple times per day
Stools soft to loose, yellowish
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
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
Thank you for taking the time to complete this questionnaire.
New Client Questionnaire
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