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Health Consultation Form
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> Health Consultation Form
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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
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