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Health Consultation Form

Home > Health Consultation Form

If you are a human and are seeing this field, please leave it blank.

Name:

Email:

Phone:

DOB:

Main reason for coming ie chief complaint:

Brief health history:

Body weight

Low, hard to gain
Medium
Overweight, gains easily

Body frame

Slim
Medium
Large

Eyes

Small, dry, quick, black, brown
Gray, green, hazel, blue, light-sensitive, intense gaze
Large, calm, attractive, kind

Lips

Dry, cracked, black or brown tinge
Red or yellowish, inflamed
Smooth, oily, pale, whitish

Teeth

Crooked, big, thin gums
Medium, soft, yellow, tender gums
Healthy, large, white. strong gums

Skin

Thin, dry, rough, dark
Smooth, oily, fair, rosy, freckled, nevi, sunburns easily
Thick, oily, white, pale

Hair

Dry, brown, black, knotted, brittle, breaks easily
Straight, oily, blond, red, grey, thinning, bald
Thick, oily, curly, wavy, luxuriant

Nails

Dry, rough, brittle, break easily
Sharp, flexible, pink, lustrous
Thick, oily, smooth, polished

Hips

Slender, thin
Medium
Large

Joints

Small, cracking
Medium
Large, lubricated

Perspiration

Less
More
Average

Temperature

Cold extremities
Warm
Cool, Moist

Menses

Spotty, irregular, cramps
Intense, heavy
Strong, regular

Appetite

Irregular, scant
Strong, unbearable
Slow, steady

Digestion

Irregular, gassy
Fast, acidic, burning
Slow, mucous

Thirst

Changeable
Excessive
Low

Elimination

Hard, dry, constipation
Loose, soft, many, diarrhea if stressed
Think, oily, sluggish; regular

Strength

Poor
Good
Excellent

Emotions under stress

Anxious, fearful, uncertain
Irritable, impatient, angry, jealous
Calm, greedy, clinging

Intellect

Quick but faulty
Moderate, accurate
Slow, exact

Memory

Recent good, long-term poor
Moderate
Slow to learn, long-term excellent

Moods

Change quickly
Slowly changing
Steady, non-changing

Dreams

Many, quick, active, frightening
Violent, fiery
Watery, romantic

Sleep

Light, interrupted, insomnia
Short but sound
Deep, prolonged

Mantra

I offer you peace. I offer you love. I offer you friendship. I see your beauty. I hear your need. I feel your feelings, my wisdom flows from the Highest Source. I salute that source in you. Let us work together for unity and love.

- Mahatma Gandhi

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