can you please tell us more info on her and her history? fill this out
Name or initials (no real names, must be anonymous)
Marital status and children if applicable
Ask the person what their main reason for wanting help is. They may have many other health concerns, but knowing what the main thing that is bothering them can be quite telling. Try to be as specific as possible here. Instead of listing ?pain? list what type of pain, the frequency, duration etc.
Any other complaints that they might have.
Medications they are taking
This needs to be very specific. The name of the drug, the amount they take and how long they have been taking it.
Western Medical Diagnosis
Have they been diagnosed with any diseases or conditions by a doctor?
Serious Illness, Hospitalizations, Accidents or Surgeries
What, when, etc.
Ask people what they ate that day. The day before. What are their favorite foods? What are their least favorite foods? What are the healthiest things they eat? Least healthy things? Ask specifically about foods that we know cause problems. Do they eat processed foods, canned foods, sugar, coffee, sodas, etc. What foods do they specifically avoid?
Asking a point blank statement about someone?s digestion will probably not get you far. Questions have to be specific. Do you have gas or bloating? Heartburn? Ulcers? Always give frequency and severity. Do they have a low or high appetite? Gallstones? Hemorrhoids, pain after eating?
Ask about bowel movements! How many times a day? Are the stools loose or well formed? Do they smell particularly strong? Is there mucus or blood in the stool? Do they have to strain or do they have a severe urgency?
How often do they urinate during the day? (If their main complaint revolves around urination (UTI, etc) then you may need to ask more questions here. Do they have clear copious urine, scanty urine, is it strong smelling? Do they have edema? Kidney stones? Do they get frequent urinary tract infections?
How many hours a night do they sleep. Do they wake rested? When do they go to sleep? When do they wake up? Do they wake up during the night? If they have troubled sleep ask specific questions about when they sleep and when they wake up.
Palpitations, medical problems, family history, shortness of breath, varicose veins, bleed easily, bruise easily, edema, high blood pressure, low blood pressure
Exercise: Ask them specifically what they do, how many times a week? Is it moderate? Weight training? Yoga?
Emotional Health: What emotions do they feel most frequently? Are they happy with their life?
How often do they get a cold or flu? Do they have seasonal allergies? Have they been diagnosed with an autoimmune disease? Cancer? Do they have food allergies?
Skin, hair, teeth and nails
Do they have rough skin, dry skin, rashes? Do they have healthy hair? Have they noticed sudden loss of hair? Do they have healthy teeth and gums? Mouth sores? Dry mouth, excess saliva, painful jaw?
Do they tend to feel warm? cold? Is there a particular part of their body that they notice is warm or cold? Do they get flashes of heat? Night sweats? Feelings of heat in the evening?
Are they satisfied with their energy levels? Is there a high point and/or a low point for them during the day.
Do they have a chronic cough? Shortness of breath? Dry throat? Sneezing, stuffy nose, asthma, bronchitis, chronic runny nose?
Are they menstruating? Peri-menopausal? Menopausal?
If menstruating, how long is their entire cycle? (28 days? 31 one days, etc) Is it regular or irregular? How many days do they menstruate? Do they have a heavy or light flow of blood? What color is it? red? pink? brown? Is there clotting? Do they have cramps? (How severe, how long, etc) Breast tenderness? Mood swings? Do they have a low libido?
Do they have STDs? HIV? HPV?
Have they been diagnosed with any reproductive diseases? Pelvic inflammatory disease, fibroids, endometriosis, cervical dysplasia? Do they have any vaginal discharge? vaginal dryness?
Have they been pregnant before? How many children? Are they currently pregnant (what trimester)? Breastfeeding?
How is their prostate health? Do they have any pain in the prostate or penis or groin? Do they have pain upon ejaculation or urination? Do they wake up in the night to pee? Have they been diagnosed with BPH? Do they have any problems getting and/or maintaining an erection? Do they have a low libido?
Do they have STDs? HIV? HPV?
At the end always ask, ?Are there any other concerns you would like to share with me??