Constitutional Intake Form Name_______________Date_____
advertisement
Constitutional Intake Form Name_______________Date_____ Phone__________e:mail______________ UPPER GI __ Sometimes nausea in mornings __ Sometimes nausea in evenings __ Sometimes excess salivation __ Mouth frequently too dry __ Duodenal ulcer __ Stomach ulcer __ Sometimes foul burps __ Butterflies in stomach __ Seldom eat breakfast __ Often don’t finish meals __ Often eat to calm down __ Receding gums __ Frequent use of alcohol __ Frequent poor appetite __ Strong, demanding hunger __ Bitter taste in morning __ Dragon breath in morning __ Acid indigestion at night __ Frequent mouth or cold sores __ Sometimes difficulty in swallowing __ Indigestion after eating LOWER GI __ Stools loose with gas __ Constipation with gas __ Frequent constipation __ Digestion unusually rapid __ Loose stools when tired/stressed __ Light colored, hard stools __ Dark, soft stools __ Quick defecation after eating __ Intestines often bloated __ Constipation with hemorrhoids __ “ w/painful defecation __ “ w/hard, marbly stools __ “ w/ fully formed stools __ “ “ alternate w/diarrhea __ Frequent need for laxatives __ Tongue often coated __ Floating stool, fat floats in water __ Undigested food particles in stool __ Greasy, smelly stools __ Dry, flaky skin __ Night blindness __ Hard bumps on the back of the arm __ Bruises easily LOWER URINARY TRACT __ Frequent urination, small amounts __ Infrequent urination, copious __ Sometimes dribbles urine afterwards __ Frequent bladder infections __ Demanding and sudden need to urinate __ Mucus in urine __ Benign prostatic hypertrophy (males) __ Dull ache after urination LIVER __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ RENAL __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Dry, even scaly skin Moist, sometimes oily skin Hives from food or drugs Hay fever or asthma Reactions to VOG Craves proteins, fats Craves sweets, or fruits Frequent trouble digesting fats Acne on face and buttocks Seems to have low blood sugar Had hepatitis in past Frequent use of alcohol Work with solvents Frequent minor illnesses Fever w/sweat when sick Don’t sweat when sick Craves shade Craves sun Nails split, brittle, weak w/ridges Facial twitches Blurred vision Eyes often red, inflamed Tremors in hands or neck Standing too quickly makes pulse roar in ears Standing too quickly causes faintness, dizziness Wakes up at night to urinate Frequent blushing or flushing Water retention with change of weather Moderate high blood pressure, craves fats Moderate low blood pressure, craves sweets Frequent thirst Craving for salt Urine always light colored Urine usually darker Frequent masturbation Sexual desire increased Sexual desire decreased Chronic lower back pain with sore knees Impaired hearing Joints hurting when weather changes Dry skin Constipation Osteoarthritis Depressed for long periods REPRODUCTIVE – ALL __ Sweat freely with strong scent __ Oily skin, facial acne __ Dry skin, cold hands and feet WOMEN __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Cycle more than 28 days Cycle less than 28 days Water retention before menses, hips, breasts Water retention before menses, feet, hands Craves fats, proteins before menses, usually Craves sweets before menses, usually Sides of breasts tender before menses Miss some periods Menses slow starting with cramps Palpitations before menses Menstruation lengthy, frequent cramps Menstruation short, defined, few cramps Frequent Class II Pap Smears History of PID(pelvic inflam.disease), cervicitis Miscarriages, problem pregnancy Period early with altitude change Period late with altitude change Tried, but couldn’t handle birth control pills Frequent candida/type infections Frequent vaginal herpes MEN __ __ __ __ Frequent cannabis use Pain or ache after orgasm Benign prostatic hypertrophy Difficulty maintaining erection even if in mood RESPIRATORY __ Shortness of breath when standing or walking __ Tobacco smoker __ Easy coughing of mucus __ Difficulty swallowing mucus __ Rapid, shallow breather __ Sometimes wake up gasping for breath __ Yawns frequently __ Sometimes hyperventilates __ Frequent chest colds __ Frequent nose bleeds __ Face, eyes get puffy CARDIOVASCULAR __ Slow, strong pulse __ Fast, light pulse __ Frequent physical activity __ Warm bodied __ Cold bodied __ Sometimes dizzy or faint __ Hands warm, sweaty __ Hands cold, clammy or dry __ Palpitations as an adolescent or before menses __ Hypertension, responds to diuretics __ Hypertension, not responding to diuretic __ Bad dreams LYMPHATIC __ Recuperates quickly if ill __ Recuperates slowly if ill __ Injuries heal quickly __ Injuries heal slowly __ Eczema, dermatitis __ Asthma or hay fever __ Arthritis or rheumatism __ Digests fats easily __ Digests fats poorly __ Frequent low level infections __ Depression, Frustration SKIN __ __ __ __ __ __ __ Skin eruptions superficial, come to a head Skin eruptions deep, not coming to a head Skin on trunk is dry Oily scalp or hair Dry scalp or hair Cracks, fissures on heel, feet, slow healing Nails brittle, split MUCUS, FLUIDS, MOISTURE, YIN ELEMENT __ Sores, cracks, on mouth, anus, vagina __ Lips often dry, chapped __ Food often causes intestinal pain __ Feelings of hunger without desire to eat __ Gets sore throat easily __ Gum problems __ Frequent nose bleeds __ Hot spells, feverishness esp. in late afternoon __ dry throat with thirst, dry tongue, dehydration, fatigue, mental & physical unrest __ Heat in cheeks, soles, palms or sternum __ Heat exhaustion __ Diabetes __ Peri menopausal syndrome __ Chronic low grade fevers __ Constipation with small, hard dry stool __ Scanty, delayed or absent periods __ Postpartum women __ dry, irritating, unproductive cough, chest pain, headache __ Sensitive to hot weather __ Excessive intake of spicy food __ Excessive physical activity __ High stress levels __ Insufficient water intake __ Feelings of hunger without desire to eat Constitutional Intake Form Name_______________Date_____ Phone__________e:mail______________ THYROID __ Warm, moist skin __ __ Over weight __ Thin __ Mild tachycardia __ __ Lethargic during day __ __ Troubled short sleep __ Rapid respiration __ Rapid transit time under 15hr. with loose stool __ Dry skin, waxy, dry scalp __ Hair stops growing and splits __ Slow transit time (constipation) __ Long cycles, over 38 days __ Sluggish eyes __ Depression __ __ Manic-depressive duality __ Poor concentration __ Frequent urination __ Dramatic extroverted personality __ Introverted personality VENOUS BLOOD __ Fatigue __ Chronic constipation __ Varicose veins, hemorrhoids __ Heaviness in legs, dull ache after prolonged standing __ Edema, pigmentation around ankles __ Leg cramps at night __ Skin rashes, eczema __ Under tongue veins large & purple __ Cold extremities BLOOD __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Gum problems Awakens & can’t go back to sleep Thinning/falling hair Weak vision esp. at night Easily dizzy Floaters in the eyes Scanty, delayed, irregular, or absent periods Chronic fatigue, low vitality Long term stress or debility (postpartum) Weight loss Tendency, seemingly, to anemia Recurring, chronic infections Tendency to depression Dry or withered skin Pale lips, nails, & lower eyelids Cold extremities Emotional apathy Mental dullness Fingernails split from top to bottom Weak, saggy skin INFLAMMATION- CHRONIC __ Rheumatoid arthritis __ Lupus __ Fibromyalgia __ Asthma, semi-asthma, wheezing __ MS __ Stuffy nose before bedtime, congested sinuses __ Leaky gut, toothpaste squeezing stool __ Dull ache when eating on right side, bloated colon __ Eczema, psoriasis __ Sore joints/knees/ shoulders __ Elevated liver enzymes, reddish tongue with red tip, flushed face __ White/yellow coated tongue with raised bumps in the back GENERAL Mark conditions that are frequent. If it is mild, mark “1”; if it is a dominant condition, Mark “2” __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Aluminum cooking vessels Brown spots, bronzing of skin Can’t gain weight Can’t lose weight Can’t get started without coffee Chemical or spray poisoning Cry easily without seeming cause Earaches Eat often or else faint/nervous Headaches Headaches in the morning, wearing off Heart palpitations when hungry Heart palpitations after eating Highly emotional Highly controlled Recent increase in weight Lack of sensation somewhere in the body Likes depressants Likes stimulants Frequent muscle cramps Pollution heavy in work or home environment Ringing in ears Pulse speeds up after eating Sensitive to cold weather Sensitive to hot weather Sensitive to high humidity Sensitive to low humidity Stuffy nose during the day Stuffy nose in evening, night List the herbs, supplements, pharmaceutical medication you are currently taking: _________________________________ List significant family health history: ____________________________________ Additional things you wish to mention: EVALUATIONS AND RECOMMENDATIONS: ____________________________________
