The School of Traditional Western Herbalism Community Clinic
www.portlandherbalschool.com
2714 NE Alberta Street, Portland OR 97211
portlandherbalschool@gmail.com
Holistic Health History:
Name:________________________________________________________________________________________________
Gender: Female ☐ Male ☐ Other ☐__________________________________
Ethnic/Cultural Background: Mother’s side ____________________________Father’s side ____________________________
Date of birth:________________________________________ Age: __________
Address
Suite/Street:________________________________________ City: ___________________ Postal Code: _______________
Phone number (home): ______________________ (work): _______________________(cell/pager):____________________
Email address: _________________________________ Website: ___________________________
Employment Status: ☐Full time ☐Part Time ☐Retired ☐Unemployed ☐Other ______________________
Occupation/Student status: ☐Full time ☐Part Time Where:__________________________________
Relationship Status: ___________________________________________
Children (#/ages): __________________________________________________
How did you find out about the School of Traditional Western Herbalism clinic?
____________________________________________________________________________________________________
In order to best support your wellness, it is very important to have a detailed understanding of your history. Please take
your time in completing these questions as accurately as possible.
What health concerns bring you here today?
Primary:____________________________________________________________________________________________
____________________________________________________________________________________________________
___________________________________________________________________________________________________
____________________________________________________________________________________________________
___________________________________________________________________________________________________
Where is it located?
What is it like?
How severe is it?
(on a scale of 1-10 with ‘10’ being the most severe being unbearable, what level is it now?) ___ Past month ___
___________________________________________________________________________________________________
When did you first notice it?
How long does it last?
When do you notice it?
What makes it better or worse?
Is there anything else that seems to relate to it?
Secondary:_______________________________________________________________________________________
______________________________________________________________________________________________________
___________________________________________________________________________________________________
Additional comments:
Are you currently receiving care from any other health professional(s)?
Medical doctor/ND/Nurse Practitioner/Psychiatrist/Chiropractor/Massage Therapist/Other healing practitioner: (if so, please
list) ________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Have you received a medical diagnosis? Yes ___ No___ For what condition(s)?___________________________________
____________________________________________________________________________________________________
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Are you currently using any supplements, vitamins, herbs, and/or pharmaceutical medication or drug? Please continue on a separate
page if necessary. Please bring all your supplements, herbs, and/or medications to your first appointment if possible.
Pharmaceutical
/latin Name
Brand name
Strength
Dose
Frequency
Duration
Do you have any infectious diseases that you know of? ☐Yes ☐No
If yes please list ______________________________________________________________________________________
____________________________________________________________________________________________________
Is there any chance that you are pregnant? ☐Yes ☐ No
Do you have any known allergies or sensitivities (drugs, pollens, foods, etc)?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Is there any reason you cannot ingest herbal remedies prepared in food-grade alcohol?_______________________________
Have you ever had surgery or been hospitalized? (Please provide the date and reason)
____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________________
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Please describe any accidents or injuries in the last five years:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
More than five years ago:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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Family Medical History
Please complete this section only for any family members with particular health problems.
Relationship Age (if deceased, age at death) Health issue
Mother
Father
Siblings
Children
Grandmother
Grandfather
Other:
Personal Health Information and Habits
Height: __________ Current Weight: _________Weight 1 year ago: __________ Ideal weight:_______
Are you a smoker? _____ Years? ____ Amount? ____ Have you smoked in the past? ____ When did you quit?___________
Do you use recreational drugs? _____yes ____no.
What types? ___________________________________________________________________________
____________________________________________________________________________________________________
How often? _____________times/week.
Regular Exercise: Yes/No Frequency: _____times/week
Type: _______________Duration? ___________________
2
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:
Good day:________________________________________________________________________________________________
Rushed/Stressed Day:_______________________________________________________________________________________
Lunch:
Nutritious day:____________________________________________________________________________________________
Less Nutritious Day:_______________________________________________________________________________________
Dinner:
Nutritious day:____________________________________________________________________________________________
Less Nutritious Day:_______________________________________________________________________________________
Snacks:
Nutritious day:____________________________________________________________________________________________
Less Nutritious Day:________________________________________________________________________________________
Do you eat sweets and desserts? ☐Yes ☐No How often? _______times/week. How much? _______ servings/day.
Do you now or have you ever followed a restricted diet? Please describe and indicate when & for what reasons:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
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 daily? ☐Yes ☐No How often? ________times/week. How much? ____glasses/day.
PART TWO: HEALTH HISTORY
Please number any symptom you have experienced according to the following scale, and if you have experienced it in the past
write a P next to the number your write in the box. If you never have the symptom, leave it blank.
1.
2.
3.
Rarely have the symptom
Occasionally have the symptom (not severe)
Occasionally have the symptoms (moderate-severe)
4.
5.
Frequently have the symptom (not severe)
Frequently have the symptom (moderate-severe)
Skin
☐Pimples
☐Dry ☐Moist ☐Oily ☐Red/Irritated ☐Pale
☐Acne
☐Feels cool/cold ☐Feels warm/hot
☐Recent moles of unusual shape or color
☐nightime sweating ☐daytime sweating
☐Recent changes in skin texture
☐Rashes
☐Excessive hair growth. Where______________
☐Poor healing sores
Hair
☐Hives
☐Dandruff
☐Itching
☐Irritated or itchy scalp
☐Eczema
☐Hair loss/Thinning. Where____________________
☐Psoriasis
Any other noted problems with your skin, nails or hair?
____________________________________________________________________________________________________
Head, Eyes, Ears, Nose and Throat
☐Glaucoma
☐Headache ☐migraines
☐Blurred vision
☐Poor vision
☐loss of vision
☐Eye pain
☐Earaches
☐Redness in eyes
☐Poor hearing
☐Floaters
☐Ringing in ears ☐swishing, roaring, or pulsing in ears
☐Cataracts
☐Fullness in ears ☐discharge from ears
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☐Sore throat
☐Bleeding gums
☐Canker sores
☐Cold sores, if yes how often? _________times/year
☐Grinding teeth
☐Facial pain
☐Clicking jaw
☐Jaw pain
☐Mucous in throat
☐Nosebleeds
☐Dizziness
☐Frequent colds
☐Swollen glands
☐Nose Bleeds
☐Allergy symptoms
Any other problems with your head, eyes, ears, nose or throat?
____________________________________________________________________________________________________
Respiratory
☐Cough ☐chronic ☐acute
☐clear/white mucus ☐yellow/green/orange mucus
☐Asthma
☐Hay fever/Allergic rhinitis
☐Seasonal allergy symptoms
☐Runny/stuffy nose
☐Bronchitis
☐Coughing blood
☐Pneumonia
☐clear/white mucus ☐yellow, green, orange mucus
☐Pain on breathing
☐Asthma
☐Shortness of breath without exertion
☐Bronchitis
☐Difficulty breathing when lying down
☐Emphysema
☐Production of phlegm, if yes what color?___________
☐Sinus infection(s)
☐allergies such as mold, dust, chemicals, cleaning products, scents, perfumes, paint etc_________________________
☐Any other respiratory issues?___________________________________________________________________________
Cardiovascular
☐High blood pressure - specify if known_____________
☐Low blood pressure - specify if known______________
☐Chest/heart pain
☐Fainting
☐Irregular heart beat
☐Cold hands or feet
☐Numbness or tingling in fingers or toes
☐Ankle swelling
☐Palpitations - ☐with anxiety ☐without anxiety
☐Easy bruising
☐Varicose veins
☐Blood clots
☐Breathing difficulties
☐Hemorrhoids
Any other concerns with your heart or circulation?
____________________________________________________________________________________________________
Gastro-Intestinal
☐Nausea
☐Vomiting
☐Diarrhea – for how long_______________
☐color__________________
☐Constipation
☐Alternating diarrhea & constipation
☐Bad breath
☐Indigestion
☐Abdominal pain
☐Heartburn
☐Gas
☐Bloating
☐Blood in stools – what color_____________________
☐Mucous in stools
☐Rectal pain
☐Hemorrhoids
☐Food cravings - specify__________________________
☐Poor appetite
☐Gallstones
☐Ulcers
☐Difficulty swallowing
☐Colitis/IBS
☐Liver problems
☐Hepatitis
☐Dysentery
☐Parasites
4
How many bowel movements do you have a day? ☐<1 ☐1 ☐2 ☐3 ☐4+ (if less the 1/day – how often________________)
How would you describe your bowel movements? ☐Loose ☐Normal ☐Hard ☐Tarry ☐Varied_____________________
Do your stools: float? ☐sink? ☐have a bad odor? ☐have no odor? ☐
Do you rely on: ☐Enemas ☐Laxatives ☐Coffee ☐ Cigarettes ☐Purgatives for bowel elimination? If yes, how often?
____times/week
☐Stool color: pale___light brown____dark brown___ Black____ Bloody______(dark blood____ bright red blood____)
Any other digestive problems?
____________________________________________________________________________________________________
Do you have any known food allergies or sensitivities – or have you noticed digestive issues after eating:______________
____________________________________________________________________________________
___________________________________________________________________________________
Do you avoid any particular food:_____________________________________________________________
Urinary/Kidneys
Urine: ☐dark color ☐light yellow/ pale
☐Painful urination
☐Frequent urination (day ____or night_____)
☐Blood in urine
☐Urgency of urination
☐Kidney/bladder stones
☐Irregular flow
☐Difficulty holding urine
☐Decrease in flow
☐Water retention
☐Burning urine
☐Difficulty stopping or starting
☐Interstitial cystitis
Any other problems with urination or kidney function?
____________________________________________________________________________________________________
Musculoskeletal/Nervous System
☐Muscle weakness
☐Muscle Tension
☐Reduced range of movement
☐Neck pain
☐Muscle pain
☐Stiffness
☐Back pain
☐Jaw pain
☐TMD or TMJ
☐Arthritis - ☐Osteo ☐Rheumatoid
☐Shooting pains
☐Paralysis
Endocrine/Metabolic
☐Sensitive to heat/cold
☐Excessive sweating
☐Night sweats
☐Hypoglycemia
☐Insulin resistance
☐Dry Skin
☐Hypothyroid
☐Hyperthyroid
☐Hashimoto’s
☐Dizziness
☐Fibromyalgia
☐Stiff joints
☐swollen joints/fluid in joints
☐Joint pain
☐Acute injury ☐Chronic pain/old injury
☐broken bone ☐Sprain ☐Strain
☐Numbness ☐Tingling - where__________________
☐Seizures
☐Issues with taste or smell________________________
☐Memory loss
☐Stress level - ☐high ☐medium ☐low
☐Chronic fatigue
☐Fevers
☐Chills
☐Excessive thirst
☐Slow metabolism
☐Sudden energy drops
☐Recent weight gain
☐Recent weight loss
5
Any other health concerns?
_____________________________________________________________________
Reproductive Information:
Are you taking synthetic hormones Yes/No Which one(s)______________________________________________________
Are you taking natural hormones Yes/No
Which one(s)______________________________________________________
Are you taking any other medication for the reproductive system?_______________________________________________
Have you had any surgeries of the reproductive organs inc. breasts?__________________________________When________
Are you currently or have you transitioned between genders?_______________ M>F_____ or F>M_______When_________
If so, what physical or emotional changes have you noticed if any?______________________________________________
____________________________________________________________________________________________________
Any related information or concerns_______________________________________________________________________
Male Body Reproductive & Hormonal
☐ Acne
☐incontinence
☐Benign prostatic hypertrophy or hyperplasia (BPH)
☐Low libido
☐Bleeding w ejaculation
☐Low sperm count
☐Candida albicans
☐penis cancer
☐Epididymitis
☐Premature ejaculation
☐Fatigue
☐Prostate cancer
☐Frequent urination
☐Stress
☐Hair Loss
☐Testicular cancer
☐Impotence
☐Trauma
☐Sexually transmitted diseases (STD’s)________________________________________________________________
☐Any other concerns__________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Female Body Reproductive & Hormonal
☐ Mastectomy
☐Acne
☐ Anemia
☐Ovulation issues
☐ Pain with intercourse
☐Candida albicans
☐Cervical dysplasia
☐PCOS (Polycystic Ovarian Syndrome)
☐ Discharge other than menstruation, if yes what is the
☐Pelvic inflammatory disease
color? ______________ Duration_______
☐Pregnant now
☐ Endometriosis
☐Progesterone – low___high___
☐Estrogen – low___high____
☐Prolactin – high____
☐ Fibroids
☐ Testosterone – low____high___
☐Hashimoto
☐Tubal ligation
☐Hyperthyroid
☐ Uterine cysts
☐Hypothyroid
☐Vaginal infection
☐ Hysterectomy
☐ Vaginal itching
☐ Infertility or difficulty conceiving
☐ Cancer _____________________________________
☐ Lumpectomy
☐Sexually transmitted diseases (STD’s) ___________________________________________________________________
Do you menstruate? ☐Yes ☐No
If yes, what is the length of your cycle (period to period):________days, and the duration of bleeding ________days?
Would you characterize your flow as: ☐Heavy ☐Normal ☐Light? Is the blood: ☐Dark red ☐brown ☐red ☐Light red/watery?
Menstrual Cycle:
☐Regular ☐Irregular ___________ ☐Absent (how long)_________________________________________________
Do you have premenstrual symptoms (PMS)? ☐Yes ☐No
How many days before your cycle do symptoms begin to manifest? ______ days before period
Is there any chance you could be pregnant at this time?__________________________
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Female reproductive (continued)…
☐Headaches
If you have PMS, which symptoms apply to you?
☐Increased appetite
☐Abdominal pain
☐Insomnia
☐Anxiety
☐Joint pain
☐Back or neck pain or tension
☐Migraines (when in cycle_______________________)
☐Bloating
☐Mood Swings
☐Breast tenderness/swelling
☐Nervous tension
☐Foggy Thinking
☐Nervousness
☐Craving for sweets
☐Palpitations
☐Depression
☐Poor memory
☐Sadness
☐Water retention
☐Dizziness
☐Weight gain
☐Fatigue (worse morning__,afternoon__,evening__after
eating____(after eating what______________________)
Do you have breast implants? ☐Yes ☐No If yes, are they: ☐Silicon ☐Saline ☐Other
If yes, have you noted any problem with them? ☐Yes ☐No
Date and result of last PAP smear: ________________________________________________________________________
How many: pregnancies have you had? _____; births? _____ ; miscarriages?_____; premature births?____; abortions? _____
Do you or have you recently used contraceptives? ☐Yes ☐No
If yes, which ones?
☐IUD ☐Condoms ☐Diaphragm ☐Rhythm ☐Mucous method ☐Spermicidal jelly
☐Other (please describe): _______________________________________________________________________________
Are you post-menopausal? ☐Yes ☐No
If yes, when was the approximate date of your last period?
If you have menopausal symptoms, please describe your major symptoms:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Are you pregnant at this time? (circle one)
YES NO MAYBE
Is there any chance that you are pregnant?
Do you have any other gynecological issues or concerns?
____________________________________________________________________________________________________
Psychological/Emotional – check any symptoms you are currently/recently experiencing. If in the past write (p) next to
the check box and when if you remember.
□ Severe headaches
□ Panic attacks
□ Fatigue/Exhaustion
□ Fear of something unknown
□ Dizziness/faintness
□ Shortness of breath
□ Numbness/tingling
□ Fear of dying
□ Periods of anxiety
□ Irritability
□ Excessive sweating
□ Agitation
□ Heart racing/pounding
□ Loss of appetite
□ Trembling/shaking
□ Memory problems
□ Excessive fears
□ Exhaustion/tiredness
□ Poor concentration
□ Nightmares
□ Severe worry
□ Sleeping excessively
□ Nervousness
□ Insomnia
□ Periods of feeling too good/high
□ Difficulty falling asleep
□ Body tension
□ Low self-esteem
□ Unresolved grief
□ Crying spells
□ Guilt feelings
□ Temper outbursts
□ Poor judgment
□ Aggressive behaviors
□ Suicidal thinking
□ Depressed mood
□ Recurring intrusive thoughts
□ Urges to perform repeated acts
□ Sexual concerns
7
Sleep
How many hours do you sleep per night on average:____
What is your regular bedtime: ____
Do you wake up: rested___somewhat tired__ very tired___
Is your sleep: continuous___ interrupted____ (by what:_____________________)
On average how many times do you wake up per night___
If you wake up, do you easily fall back asleep____
How long does it usually take you to fall asleep ___
Do you have nightmares: often___ rarely___ never____
Do you have night sweats:___
What medications or herbs do you take to help you sleep________________________________________________________
Additional
☐Memory problems
☐Numbness, if yes,where? _______________________
☐Irritability
☐Seizures
☐Migraine
☐Headaches
☐High stress levels
☐Fatigue
☐Lack of motivation
☐Loss of balance
☐Lack of coordination
☐Difficulty concentrating
☐Foggy or spacey feeling
☐Muscle spasm/twitching
How many hours do you sleep each night? ______
Do you have any other neurological problems?
____________________________________________________________________________________________________
To the best of your knowledge, have you ever been exposed to pesticides, toxic chemicals, heavy metals, radiation, or other
toxins encountered beyond what might be expected in one’s day to day life?
_____________________________________________________________________________
Outlook on Life
How do you feel about the following areas of your life? Please check appropriate boxes and make any comments you would
like to.
Excellent - Good - Fair - Poor

Self

Spouse/Partner

Sex

Family

Life purpose

Finances
Are you able to express your feelings and emotions easily? ☐Yes ☐No
Is there an excess of stress in your life? ☐Yes ☐No If yes, what is causing you stress?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Do you have tools or techniques to relieve stress? ☐Yes ☐No
Are you satisfied with your current living/working environment? ☐Yes ☐No
If there is one thing in your life that you would like to change right now, what is it?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Do you sleep well? ☐Yes ☐No
What feelings do you most often experience in your life?
☐joy ☐happiness ☐ acceptance ☐ anger ☐sadness ☐fear ☐anxiety ☐sympathy ☐worry ☐ depression ☐guilt
☐confusion
☐ self-doubt
Vision Statement
What is your desired goal for your visit today?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
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_____________________________________________________________________________________________
Waiver of Liability
I, the undersigned, hereby confirm that I am consulting with________________________________of my own free will. I
understand that_______________________________________is not licensed as a physician to diagnose, cure or treat any
illness or medical condition, nor to prescribe medications. I understand that there will be no diagnosis made, nor prescriptions
given, but rather that ______________________________will offer an assessment of my general wellbeing, as well as dietary,
herbal, and nutritional recommendations to support my health and emotional balance. I understand that the information
received in this and any consultation with ______________________________is not in any way to be considered medical
advice, nor is it to be considered a substitute for medical advice. I understand that it is important that I continue to seek medical
care with my medical doctor, Naturopath, or nurse practitioner as usual, and to confirm any addition of herbs and
supplements to my diet with this healthcare provider. If I am already taking prescription medications of any kind, I hereby
confirm that I will not discontinue use of such medications without consulting with my prescribing healthcare provider. I also
understand the importance of frequent monitoring of any new health supporting protocol to revise the recommended protocol
as appropriate, and confirm that I will immediately report any new or unusual symptoms to _________________________and
to my physician (if I am currently seeing a physician for a medical condition or illness).
Signature: __________________________________________________________ Date _________________________
Print name: _________________________________________________________
All case history notes and medical information recorded during the consultation are kept strictly confidential. Your
personal and health related information will not be released to any person or agency except with your authorization or
where required by law.
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