STWH Energetic Interview Protocol (Format Individually for each client)
PART ONE: PERSONAL INFORMATION from intake
Name:________________________________________________________________________________________________
Ethnic/Cultural Background: Mother’s side ____________________________Father’s side ____________________________
Age: __________
Primary Health Concerns Summary from Intake:






OPQRST: (Paul Bergner’s Acronym)
o Onset,
o Provoke/Palliate
o Quality (what’s it like)
o Referral/Radiation (does it radiate or refer to other areas)
o Severity (scale of 1-10),
o Timing (when, how long, how often, etc)
Location,
o Does it radiate
o Quality
o Severity
o d. Timing
When did your first notice it
How long does it last
How often does it come
When is it better or worse
o Setting in which it occurs, environmental factors, activities, context, emotional setting or reactions, etc.
o Factors that make it better or worse
o Associated symptoms or manifestations
Severity: (on a scale of 1-10 with ‘10’ being the most severe being unbearable, what level is it now?) ___ Past month ___Past
two weeks______
Is there anything else that seems to relate to it?
Practitioner Questions:
 ___
 ___
 ___
Secondary health concerns Summary:

OPQRST:
o Onset,
o Provoke/Palliate
o Quality (what’s it like)
o Referral/Radiation (does it radiate or refer to other areas)
o Severity (scale of 1-10),
o Timing (when, how long, how often, etc)
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Other Related issues/hospitalizations, surgeries, infectious diseases, trauma, stressors:
Practitioner Questions:
 ___
 ___
 ___
Additional comments or questions:
Currently receiving care from other health professional(s)?
Medical doctor/ND/Nurse Practitioner/Psychiatrist/Chiropractor/Massage Therapist/Other healing practitioner: (if so, please
list)
Medical diagnosis? Yes ___ No___ For what condition(s)?___________________________________
____________________________________________________________________________________________________
Current supplements, vitamins, herbs, and/or pharmaceutical medication or drug?
Pharmaceutical
/latin Name
Brand name
Strength
Dose
Frequency
Duration
Potential Side Effects – correlating with presenting complaints:
Known allergies or sensitivities (drugs, pollens, foods, etc)?
Concerns about ingesting herbal remedies prepared in food-grade alcohol?
Typical Diet – as accurately as possible please describe what you typically eat on a daily basis
*Emotional issues related to food you want to address ☐yes ☐no - prefer not to fill out diet diary at this time
☐
Breakfast:
Nutritious day:_____________________________________________________________________________________________
Less Nutritious Day:_______________________________________________________________________________________
Lunch:
Nutritious day:____________________________________________________________________________________________
Less Nutritious Day:_______________________________________________________________________________________
Dinner:
Nutritious day:____________________________________________________________________________________________
Less Nutritious Day:_______________________________________________________________________________________
Snacks:
Nutritious day:____________________________________________________________________________________________
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Less Nutritious Day:________________________________________________________________________________________
____________________________________________________________________________________________________
Do you drink alcohol? ☐Yes ☐No If yes, what types? __________________________________How often? ___times/week.
Do you drink coffee? ☐Yes ☐No How often? ____________times/week. How much? ____cups/day.
Do you drink tea? Black/green/herbal ☐Yes ☐No How often? ____________times/week. How much? ____cups/day.
Do you drink soda/pop? ☐Yes ☐No How often? ____________times/week. How much? ____cups/day.
Do you make a point to drink water? ☐Yes ☐No How often? ________times/week. How much? ____glasses/day.
Other Practitioner Questions by Body System:
(omit sections that don’t have client concerns)
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Smoking:
Yes__ No __ Occasionally___ Frequency__________________________Years? ____ Amount? ____
Exercise:
Regular Exercise: Yes/No Frequency: _____times/week
Type: _______________Duration? ___________________
ENERGETIC PATTERNS
Respiratory
Tension Pattern:
☐Shallow or rapid breathing, ☐tightness in throat or ☐chest (tightness in chest in particular should be medically evaluated), ☐
stiff tense tongue.
Weakness Pattern: ☐weak voice, ☐poor lung/breath capacity, ☐ weak cough/difficulty expectorating mucus, ☐ frequent
respiratory infections, ☐quivering tongue.
Damp Pattern: ☐ mucous discharges or ☐stagnant mucus anywhere in respiratory tract, ☐wet swollen tongue w ☐scalloped
edges.
Dryness Pattern: ☐dry irritated mucous membranes, ☐sinuses, ☐dry mouth, ☐dry scratchy throat, ☐laryngitis, ☐dry cough,
☐wheezing (could be w tension), ☐dry phlegm, ☐dry ☐thin tongue.
Heat Pattern: ☐Acute upper respiratory infection with ☐fever, ☐inflammation; ☐lower respiratory infection with ☐Dry heat or
☐damp heat (phlegm), ☐feels hot, ☐Red tongue with ☐yellow coating thick/thin, ☐without coating, ☐with patchy coating.
Cold Pattern: ☐feels cold/☐prefers warmth, ☐chills, ☐clear or white mucus, chronic ☐upper and ☐lower respiratory
conditions with cold symptoms, ☐pale tongue with ☐thick white coating
____________________________________________________________________________________________________
Cardiovascular
Tension Pattern
☐Rapid heart beat, ☐palpitations, ☐high blood pressure
Weakness Pattern: ☐poor coronary circulation, ☐ weak heart muscle, ☐poor peripheral circulation, ☐weakness of heart
function, ☐sluggish flow of blood and qi, ☐ with depression or ☐anxiety
Damp Pattern:
(Blood) ☐Poor pelvic circulation with pelvic congestion, ☐sense of heaviness or fullness in uterus or pelvis, ☐sense of
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dragging discomfort before period, ☐feeling of sluggishness, ☐heaviness in legs, ☐varicose veins or spider veins,
☐hemorrhoids, ☐low back ache, dysmenorrhea, ☐benign prostate hyperplasia, ☐heavy menstrual flow with clots,
(Water) ☐Heavy, tired, sluggish feeling in body (particularly extremities), ☐fatigue, ☐poor appetite, ☐excessive thirst, ☐lack
of thirst, ☐scanty infrequent urination, ☐or frequent and copious urination. ☐Tongue is broad, flabby, swollen, wet.
(Lymph) ☐Edema anywhere in body, ☐swollen lymph nodes
Dryness Pattern: ☐Deficient blood and fluids, ☐sluggish circulation
Heat Pattern: ☐High blood pressure, palpitations, ☐toxic heat in the blood, ☐heat at the blood level, ☐reckless blood,
☐hemorrhaging, ☐red tongue, ☐forceful, ☐pounding, ☐thick pulse, ☐floating pulse.
Cold Pattern: ☐deficient circulation, ☐cold extremities, ☐blood stasis, ☐masses (☐movable, ☐immovable)
____________________________________________________________________________________________________
Gastro-Intestinal
Tension Pattern:
☐GI tension or spasm ☐alternating constipation and loose stools, ☐cramping, ☐pelvic floor dysfunction, ☐hemorrhoids,
☐fissures, ☐abdominal pain (should be evaluated by medical professional), ☐Irregular eating habits
Weakness Pattern:
☐Poor or uncoordinated digestive functions & ☐deficient digestive secretions, ☐deficient bile secretion (☐clay colored
stool), ☐poor nutrient absorption (or ☐inadequate nutrient intake), ☐weak peristalsis, ☐deficient and/or uncoordinated
nervous function in GI ☐intestinal hyper-permeability, ☐ weak intestinal musculature, ☐colonic torpor, ☐chronic loose stools,
☐diarrhea, or ☐constipation, ☐prolapse of tissues and sphincters, ☐weakness of mucous membranes, and ☐vasculature.
Damp Pattern: ☐Mucous in stool, ☐heavy, full, ☐bloated feeling after eating, ☐thickly coated tongue
Dryness Pattern: ☐deficient digestive secretions, ☐dry, hard, stool (often in pebbles), ☐painful or slow defecation due to dry
mucous membranes or size of stool, ☐with constipation.
Heat Pattern: ☐Hot dry digestive imbalance with constipation, ☐hot damp digestive imbalance with diarrhea, ☐burning
irritation in the stomach, ☐hot indigestion, ☐intestinal inflammation, ☐alternating constipation & diarrhea ☐with other heat
symptoms, ☐GI inflammation combined with systemic inflammation /fever, ☐inflamed liver (damp heat), ☐bleeding in GI
tract w other heat signs.
Cold Pattern: ☐deficient digestive secretions, ☐poor appetite, ☐slow digestive process, ☐atonic upper digestive conditions,
☐constipation or diarrhea, ☐deficient bile flow.
_________________________________________________________________________________________________
Urinary/Kidneys
Tension Pattern: ☐frequent urge to urinate, or ☐holding urine too long, ☐concentrated urine due to lack of fluid intake
Weakness Pattern: ☐weak flow, ☐dribbling after urination, ☐urinary incontinence, ☐nocturia, ☐irritation of bladder or
ureters, ☐recurring UTI’s (also cold /and immune).
Damp Pattern: ☐water congestion from weak kidney function, ☐Edema of abdomen or extremities, ☐sluggishness and
heaviness in the body, frequent or infrequent scanty urination.
Dryness Pattern: ☐scanty, ☐dark urine, ☐dehydration
Heat Pattern: ☐Hot irritated inflamed mucous membranes in ☐Bladder, ☐ureters, ☐UTI infection with heat and irritation,
☐Kidney infection or inflammation (MUST SEE MEDICAL PROVIDER IF POSSIBLE), ☐frequent urge to urinate, ☐painful
urination, ☐dark urine, ☐sediment (pus or other) in urine, ☐achy pain in ureters or bladder or kidneys (MUST BE TREATED
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ACUTELY), ☐boggy feeling in pelvis or genital region, ☐general ill feeling or malaise, ☐fatigue.
Cold Pattern: interstitial cystitis, UTI from exposure to cold
__________________________________________________________________________________________________
Musculoskeletal/Nervous System
Tension Pattern
☐Tense muscles, ☐cramping, ☐muscle spasms, ☐tight ligaments, ☐abdominal masses or lumps (should be evaluated)
☐Stiffness, ☐body movements lacking fluidity and suppleness, ☐fidgeting, ☐restless movements, ☐sore/tight neck or
shoulders or back, ☐tension headaches (all severe, long lasting, or unusual headaches should be evaluated)
Weakness Pattern:
☐muscles with lack of tone, ☐reacts poorly to exercise, ☐muscles easily fatigue, ☐overweight or underweight, ☐hyperflexibility in joints and tendons.
Damp Pattern:
☐Muscle aches, sense of heaviness, sluggishness in ☐legs, ☐arms, ☐hands, ☐feet, ☐other area______________________.
Dry Pattern: Stiff inflexible ☐muscles, ☐joints, ☐ligaments, ☐limbs, ☐lack of nourishment to muscles and bones
Heat Pattern: ☐inflammation in muscles, ☐joints, ☐ligaments, ☐tendons, ☐bone, ☐teeth, ☐nerves
Cold Pattern: ☐Rheumatic conditions, ☐arthritic conditions, ☐stiffness ☐achiness
__________________________________________________________________________________________________
Skin/Hair
Tension Pattern:
☐Dry, rough, thin, or cold skin, and or dry or itchy scalp (these are sx of dryness often co-occurring with tension – tension is
preventing flow of qi/vital force/Prana, blood, lymph, and vital fluids to skin)
Weakness Pattern:
☐Flabby or ☐thin skin with lack of luster and vitality, ☐lack of sensitivity, ☐bruises easily (should have blood work done), ☐
dry, lusterless, or thinning hair.
Damp Pattern: ☐swollen congested tissues, ☐clammy ☐moist or ☐oily skin or hair, ☐weeping eczema (hot damp).
Dryness Pattern: (Skin) ☐rough, ☐dry, ☐flaky, ☐irritated, dry eczema, (Hair) ☐dry hair or scalp, ☐brittle, ☐thin, ☐lack of
sheen.
Heat Pattern: ☐hot, ☐red, ☐inflamed, ☐irritated, ☐itchy, ☐painful, ☐blistery ☐skin or ☐scalp. Hair falling out, eczema, boils,
acne, other inflamed skin condition _____________________________________________________________.
Cold Pattern: ☐pale ☐cold skin, ☐lack of peripheral circulation,
____________________________________________________________________________________________________
Endocrine/Metabolic
Tension Pattern:
☐Nervous/irregular/sporadic energy (alternating fatigue, bursts of energy, restlessness – often wrong time of day with high
cortisol levels at night and low in morning, second wind at night, overactive mind, may have sweaty palms)
Weakness/Deficiency Pattern:
☐Poor stamina, ☐deficient energy and ☐endurance, ☐exhaustion, ☐low energy responsiveness to their social and physical
environment, ☐low tolerance to stress, ☐quickly fatigues physically and emotionally, ☐palpitations, ☐day or ☐night sweats
(should be evaluated by physician), ☐deficient Hypothalamic Pituitary Adrenal (HPA axis) function, ☐adrenal fatigue, ☐feels
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burnt out, ☐deficient reproductive hormones, ☐low thyroid or auto-immune Hashimotos, ☐chronic fatigue, ☐weak immune
system, with ☐shallow sleep, ☐waking early with difficulty returning to sleep, ☐tired in the daytime, ☐deficient
neurotransmitters.
Damp Pattern:
Dryness Pattern: ☐Deficient hormone production (such as deficient estrogen, progesterone etc), ☐can include diabetes, ☐
Heat Pattern: ☐Excessive immune response, ☐allergies, ☐autoimmune conditions, ☐excessive production of certain hormones
or neurotransmitters (prolactin, dopamine, cortisol etc – also related to stress & tension)________________________
Cold Pattern: ☐fatigue, ☐poor stamina, ☐lack of sweating, ☐chills easily/sensitive to cold, ☐wears heavier than average
clothing for weather, ☐deficient endocrine function, ☐hypothyroid
_______________________________________________________________________________________________
Reproductive & Hormonal
Tension Pattern
☐PMS, ☐cramps, ☐slow/difficult onset, ☐long or ☐irregular cycles
☐Premature ejaculation, ☐lack o sexual sensitivity, ☐difficulties with arousal, ☐anorgasmia, ☐irregular libido
Weakness Pattern:
☐Poor uterine tone, ☐scanty or absent periods, or may have ☐heavier flooding (menorrhagia), intermittent bleeding between
periods (metorrhagia), ☐uterine prolapse, ☐weakness of mucous membranes of reproductive tract, ☐deficient reproductive
hormones (☐_______________________), ☐chronic leukorrhea, ☐infertility, ☐history of miscarriage or premature births
Damp Pattern: vaginal discharges, ☐Sense of heavy dragging feeling in uterus especially before the period, ☐low back pain,
☐dysmenorrhea, ☐swollen breasts and bloating before the period, ☐Heavy flow ☐with clots.
Dryness Pattern: scanty menstruation with slow onset, vaginal dryness, dry mucous membranes, deficient hormonal production,
low libido.
Heat Pattern: ☐inflammation of or ☐infection in reproductive organs, ☐peritoneum, ☐pelvis, ☐menorrhagia, ☐heavy and/or
prolonged bleeding with bright red blood, STD’s______________________________________________________.
Cold Pattern: ☐cold uterus, ☐amenorrhea, ☐periods with sluggish and or ☐delayed onset, ☐painful cramping, ☐blood stasis,
☐heavy or ☐clotted bleeding, blood tends to be ☐dark red or ☐brown, ☐low libido, ☐abdominal masses (should be
diagnosed), ☐fibroids, ☐infertility.
____________________________________________________________________________________________________
Psychological/Emotional/Spiritual
Tension Pattern:
☐Anxiety, ☐worry, ☐emotional tension, ☐restlessness, ☐nervousness, ☐difficulty focusing/concentrating, ☐hyper-vigilance,
☐scattered thinking, ☐racing thoughts, ☐intrusive recurring thoughts, ☐restless/agitated depression, ☐anxiety disorder, ☐High
stress tolerance, ☐doesn’t listen to body (forgets to eat, sleep, drink fluids), ☐patterns of irregularity, ☐pushes self too hard
and/or self-punishing behaviors, ☐history of trauma (early childhood common) or has PTSD/ASD, ☐history of mental or
emotional stressors, ☐history of difficult relationship(s), ☐high sensitivity to environment, ☐burnout from over-work,
☐fatigue/exhaustion, ☐history of shock, ☐other mental or emotional issues.
Weakness Pattern:
☐Difficulty with focus and concentration, ☐foggy thinking/mental fatigue, ☐poor memory, ☐feeling ‘out of it’, ☐Depression
particularly with low motivation and apathy, ☐lack of will power and follow-through, ☐Flat affect, ☐emotional withdrawal,
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☐lack of engagement with environment, ☐Low self-esteem, ☐pessimistic attitude, ☐guilt and shame
Damp Pattern: difficulty with concentration and focus, poor memory, dizziness
Dryness Pattern: ☐inconsistent ☐erratic focus, ☐scattered thoughts, ☐inconsistent mood
Heat Pattern: ☐anger (internal or externalized), ☐irritation, ☐agitated mind, ☐delirious thinking, ☐rambling speech, ☐mania
Cold Pattern: ☐Dull thinking, ☐flat affect, ☐inwardly focused, ☐may be depressed, ☐lack of engagement, ☐slow movements
____________________________________________________________________________________________________
Sleep
Tension Pattern: ☐irregular sleeping habits, ☐onset insomnia (can’t stop thinking), ☐restless sleep, ☐or active restless dreams
that may wake person up.
Weakness Pattern: ☐Insomnia with shallow sleeping, ☐early waking with ☐difficulty returning to sleep, ☐morning and/or
daytime fatigue.
Damp Pattern: ☐Heavy, sluggish feeling in body may be worse in morning, evening, ☐or while lying down (if difficulty
breathing when lying down – should seek medical care – red flag for congestive heart failure)
Dryness Pattern: ☐insomnia, ☐light, restless sleep, ☐difficulty staying asleep
Heat Pattern: ☐Restless or frightening dreams, ☐nightmares, ☐delirium (☐with fever)
Cold Pattern: ☐fatigue, ☐excessive sleepiness, ☐somnolence during daytime
____________________________________________________________________________________________________
Pain
Tension Pattern:
☐Unexplainable pains (should be evaluated), ☐moving pains, ☐intermittent pains (come and go)
Weakness Pattern: ☐muscle weakness (quick to achy muscle fatigue), ☐pain better with pressure (☐abdominal, ☐headache,
☐menstrual).
Damp Pattern: ☐achy, ☐heavy, ☐dragging,
Dryness Pattern: ☐gnawing, ☐achy, ☐sharp, ☐scratchy/burning pains
Heat Pattern: ☐sharp, ☐burning, ☐zinging pain
Cold Pattern: ☐dull, ☐aching, ☐sharp, stabbing, and fixed if blood stasis
Lifestyle/Behavioral
Tension Pattern: ☐Lack of structure and regularity, ☐stressful schedule, ☐pushing self too hard, ☐not enough time for self
care (eating, sleeping, resting, exercise, fun/play, work, family, friends, life purpose, _______________________), ☐difficulty
being on time, ☐always in a rush, ☐irregular incoherent habits of all kinds (eating, sleep, fluid intake), ☐difficulty with follow
through and ☐regimen compliance.
Weakness Pattern: ☐prolonged stress or overwork, ☐burn-out, ☐no time to rest, ☐deficient sleep, ☐poor sleep hygiene,
☐inadequate nutritional intake, ☐toxic diet, ☐constitutional hereditary weakness in constitution, ☐recovering from illness
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Damp Pattern: lack of exercise, sedentary work, poor diet habits (favor damp-producing foods)
Dryness Pattern: ☐lives or works in dry environment, ☐inadequate fluid intake, ☐inappropriate /excessive use of drying
☐herbs or ☐medications, ☐not enough moisture in food.
Heat Pattern:
☐external heat influences (bacteria, viruses, toxins), ☐internal heat (fever, inflammation, other immune
response/hormonal/neuroendocrine excess), ☐relational heat -stressful conflictual or ☐abusive relationships (personal or work),
☐being chronically treated unfairly, ☐living in a controlled environment with lack of personal freedom (ex incarceration),
☐poverty (also tension &weakness), ☐experiencing societal/institutional oppression (also tension & weakness).
Cold Pattern: environmental cold, emotional coldness/withdrawal, neglect, lack of social support, cold or distant relationship
with family members, boring job, lack of fulfillment in life.
Outlook on Life:
Tongue:
 Vitality
 Body shape
 Body Color
 Coating thickness
 Coating Color
 Papillae
 Geography
Motivation:
 Low-high (1-2-3-4-5-6-7-8-9-10)
 Current motivational challenges:

Physical

Emotional

Other reflections on current level of motivation
Symptom Checklist
Assess symptoms before and after your holistic regimen or elimination/substitution diet.
1 – never have the symptom
2 – rarely have the symtom
3 – occasionally experience the symptom
4 – Frequently experience the symptom
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Presenting Complaint – Symptom Assessment
Symptom
Severity
Frequency
Secondary Complaint – Symptom Assessment
Symptom
Severity
Frequency
Other Complaint – Symptom Assessment
Symptom
Severity
Frequency
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