New Client Consultation Form
This form is for clients of Kristie Karima Burns, MH, NDat:www.HerbnHome.com. This provides a starting point for our conversations.
Please make payment and choose a date from the calendar on the website atwww.Herbnhome.comand then submit this form to:Herbnhome@gmail.com. You may
choose to have your consult by phone or IM or you may choose a date for your e-mailconsult to be finished and sent back to you. If you are consulting by e-mail please choosea date at least four days after you turn in the following form. If you choose to consult by phone, IM or video chat you may choose any open date on the calendar.
GENERAL CLIENT INFORMATIONThis section gives me a general idea of your complaints and helps me to pinpointbody systems that may need stregntheing, and physical problems you may or maynot be aware of. This section also gives insight into what may have caused thoseproblems in your lifestyle, nutrition, relationships or environment.
Note: When it says “Circle those that apply” please underline them if you are filling thisout via e-mail. I have left this form without numbers and lines so it is easier for you to fillout. You can cut and paste this into an e-mail or a word document or you can fill it outfrom this PDF and send it back to me.
Name?Age?Birthday?Who referred you to us?Why are you visiting?E-mail address?Female or Male?Do you live in the city, suburbs or country?Do you live in a house,apartment or other?How many rooms are in your dwelling?Is your dwelling sunny or dark?Who do you live with?Do you have pets? Which kind?What kind of water do you drink?Do you bathe in filtered water? .Height?Weight?Known Allergies?What did you eat for the past three days? Please be specific? Is this typical of yourdiet? In what ways is this typical or not?Do you follow any special or restricted diet at this time?What would you like to change about your eating habits?Do you eat out often?
Which restaurants?What times do you eat?Are your meals relaxed or stressful times?Who cooks at your home?Do you like to cook?Occupation?Married?How many children do you have?What music do you listen to?What is your favorite color?Are you pregnant or trying to get pregnant?Are you seeing a physician or health care practitioner for any reason?How many times do you urinate in one day?How many times do you urinate at night?How many bowel movements do you have each 24 hour period?Are your bowel movements hard, dry, soft, runny or constipated?Have you ever used tampons?Following is a list of health problems. Please circle any which apply to you: lowblood pressure, asthma, earaches, eye pains, dry or wet eyes, hay fever, sinuscongestion, sore throat, bloating, dark circles under eyes, itchy ears or eyes,emotional insecurity, dryness, itching, difficulty breathing, congestion, abdominalpain, indigestion, hyperthyroidism, and vertigo, frequent headaches, and nausea,and dizziness.From the list above, which problems do you have NOW?Are you allergic to any medications?Which ones?Which medications are you taking now?What vitamins/supplements do you take now?Have you had any major operations? Accidents?Have you had any hospitalizations? For what reason?If you are female the following is a list of health problems commonly experienced byfemales. Please circle any which you are experiencing NOW: shortness of breath,irregular menstrual cycles, heavy menstrual bleeding, bleeding between cycles,dramatic mood swings around your menstrual cycle, and hot flashes. The followingis a list of some common physical activities. Which do you participate in?: Sitting ata desk, sitting in a car, jogging/running, calisthenics, aerobics, weight lifting,walking, standing, and dancing.Which do you do and for approximately how long each week?Have you used birth control ?How many pregnancies have you had? (List any miscarriages or abortions as well?
The following is a list of health problems. Circle any that are in your family:allergies, Diabetes, disease, mental illness, asthma, heart disease, thyroid problems,liver problems, high blood pressure, and reproductive problems, and digestivedisorders.Are you able to express your feelings and emotions?Are you happy with your job?Are you happy in your marriage?Are you lonely?What is the one thing you could change in your life now if you could changeanything?Are you a nervous person? What makes you nervous?Do you sleep well?Which of the following feelings is predominate in your life? Circle which apply: Joy,happiness, sadness, fear, sympathy, low self esteem, negative feelings, and positivefeelings.The following is a list of experiences. Please circle which ones you have experiencedin the past seven years and when: divorce, loss of a loved one, loss of a job, change of residence, injury, violation of property or self, death of a close relative, death of close friend, death of acquaintance or distant relative, other.Indicate type and date of each experience: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ Are you happy with your current finances?______________________ Please answer "YES" or "NO" to each of the following statements listed below:Lack of energy?Frequent illness?Body odor or bad breath?Difficulty digesting certain foods?Frequent consumption of red meat?Female concerns?Frequent use of antibiotics?Frequent mood swings?Food allergies?Bags under your eyes?Smoking or around those that smoke?Poor concentration of memory?Heavy alcohol consumption?Poor resistance to disease?
Search History:
Result 00 of 00
00 results for result for
p.
More From This User
Notes
Load more
