DIRECTIONS: For every statement on this and the following pages, simply check or place an "X" beside all the descriptions that apply, except where otherwise indicated.
UPPER GI
___ Sometimes nausea in mornings
___Sometimes nausea in evenings
___ Sometimes excess salivation
___Mouth frequently too dry
___Duodenal ulcer
___ Stomach ulcer
___Sometimes foul burps
___Butterflies in stomach
___Seldom eat breakfast
___Often don’t finish meals
___Often eat to calm down
___Receding gums
___Frequent use of alcohol
___Frequent poor appetite
___ Strong, demanding hunger
___Bitter taste in morning
___”Dragon breath” in mornings
___Acid indigestion at night
___Frequent mouth or cold sores
___Sometimes difficulty in swallowing
___Indigestion after eating
LOWER GI
___ Stools loose with gas
___Constipation with gas
___Frequent constipation
___ Digestion unusually rapid
___ Loose stools when tired/stressed
___Light colored, hard stools
___ Dark, soft stools
___ Quick defecation after eating
___Intestines often feel bloated
___Constipation with hemorrhoids
___Constipation w/ painful defecation
___Constipation w/ hard, marbly stools
___Constipation w/ fully formed stools
___Constipation alternating with diarrhea
___Frequent need for laxatives
___Tongue often coated
LIVER
___Dry, even scaly skin
___ Moist, sometimes oily skin
___Hives from food or drugs
___Hay fever or asthma
___Crave proteins, fats
___Crave fruit or sweets
___Frequent trouble digesting fats
___Acne on face AND buttocks
___Seems to have low blood sugar
___Had hepatitis in past
___Frequent use of alcohol
___Work with solvents
___Psoriasis, eczema, dermatitis
___Frequent minor illnesses
___ Fever w/ sweat when sick
___Don’t sweat when sick
RENAL
___ Standing too quickly makes pulse roar in ears
___Standing too quickly causes dizziness, faintness
___Wakes up at night to urinate
___Frequent flushing or blushing
___Water retention with change of weather
___ Moderate high blood pressure, crave fats
___Moderate low blood pressure, crave sweets
___Frequent thirst
___Craving for salt
___Urine always light colored
___Urine usually darker
___Sometimes difficulty in swallowing
___Indigestion after eating
LOWER URINARY TRACT
___Frequent urination, small amounts
___ Infrequent urination, copious
___Sometimes dribbles urine afterwards
___Frequent bladder infections
___Demanding and sudden need to urinate
___Mucus in urine
___Benign prostatic hypertrophy (males)
___Dull ache after urination
REPRODUCTIVE - ALL
___ Sweat freely with strong scent
___ Oily skin, facial acne
___Dry skin, cold hands and feet
WOMEN
___Cycle more than 28 days
___ Cycle less than 28 days
___ Water retention before menses: hips, breasts
___Water retention before menses: feet, hands
___ Craves fats, proteins before menses, usually
___Craves sweets before menses, usually
___ Sides of breasts tender before menses
___Miss some periods
___Menses slow starting with cramps
___ Palpitations before menses
___Menstruation lengthy, frequent cramps
___ Menstruation short, defined, few cramps
___Frequent Class II Pap smears
___History of PID, cervicitis
___Miscarriages, problem pregnancy
___ Period early with altitude change
___Period late with altitude change
___Tried, but couldn’t handle birth control pills
___Frequent candida-type infections
MEN
___Frequent cannabis user
___Pain or ache after orgasm
___Benign prostatic hypertrophy
___Difficulty maintaining erection even if you
feel in the mood
RESPIRATORY
___Shortness of breath when standing/walking
___Tobacco smoker
___ Easy coughing of mucus
___Difficulty swallowing mucus
___Rapid shallow breather
___Sometimes wake up choking/gasping for
breath
___Yawn frequently
___ Sometimes hyperventilates
___Frequent chest colds
CARDIOVASCULAR
___ Strong, slow pulse
___Fast, light pulse
___ Frequent physical activity
___ Warm bodied
___Cold bodied
___Sometimes dizzy or faint
___ Hands warm, sweaty
___Hands cold, clammy or dry
___ Palpitations either as an adolescent
or before menses
___Hypertension, responds to diuretics
___Hypertension, not responding to diuretics
LYMPHATIC
___ Recuperate quickly if ill
___Recuperate slowly if ill
___ Injuries heal quickly
___Injuries heal slowly
___Eczema, dermatitis
___Asthma or hay fever
___Arthritis or rheumatism
___ Digest fats easily
___Digest fats poorly
SKIN
___ Skin eruptions superficial, come to a head
___Skin eruptions deep, don’t come to a head
___Skin on trunk is dry
___ Oily scalp or hair
___Dry scalp or hair
___Cracks, fissures on heels, feet; slow healing
MUCUS
___Sores, cracks on mouth, anus, and/or vagina
___Lips often dry, chapped
___Food often causes pain passing through
intestines
___Get sore throat easily
GENERAL
Only mark conditions that are frequent. For a mild
condition write “1. ” Dominant conditions write “2.”
___Use aluminum cooking vessels
___Awaken, can’t go back to sleep
___Bad dreams
___Blurred vision
___Brown spots, bronzing of skin
___Bruises easily
___Can’t gain weight
___Can’t lose weight
___Can’t get started without coffee
___Chemical or spray poisoning
___Chronic fatigue, depression
___Cry easily without seeming cause
___Depressed for long periods of time
___Earaches
___Eat often or else feel faint/nervous
___Eyes often red, inflamed
___Face, eyes get puffy
___Facial twitches
___Gum problems
___Tooth problems
___Headaches
___Headaches in mornings, wearing off
___Heart palpitations when hungry
___Heart palpitations after eating
___Highly emotional
___Highly controlled
___Impaired hearing
___Increase in weight (recent)
___Lack of sensation somewhere in the body
___Like depressants
___Like stimulants
___Lower back pain
___Frequent muscle cramps
___Nails split, brittle
___Nails weak, ridges
___Nosebleeds frequently
___Pollution heavy in work or home environment
___Ringing in ears
___Pulse speeds up after meals
___Sensitive to cold weather
___Sensitive to hot weather
___Sensitive to high humidity
___Sensitive to low humidity
___Sexual desire decreased
___Sexual desire increased
___Stuffy nose during the day
___Stuffy nose in evening, night
___Tendency, seemingly, to anemia
___Tremors in hands or neck
___Varicose veins
___Weight gain in upper arms/shoulders/back of neck
PLEASE ANSWER THE FOLLOWING QUESTIONS TO THE BEST OF YOUR ABILITY:
1) Are you currently under the care of a physician or other health care provider? ___ Yes ___ No
Name of your provider:_______________________________________________
2) Have you been diagnosed with a chronic condition? If yes, please describe what it is:______________ _____________________________________________________________
3) Have you been seriously ill or injured within the past 12 months? If yes, what happened:____________ _____________________________________________________________
4) Have you been hospitalized within the past 12 months? If yes, for what reason(s): ________________
_____________________________________________________________
5) Are you taking any prescription medications or receiving any kind of treatment? If yes please describe: _____________________________________________________________
_____________________________________________________________
6) Do you take any vitamin, mineral or other supplements? If so, what kind and how often?
_____________________________________________________________
_____________________________________________________________
7) Please describe what you usually eat: ___________________________________________________________
_____________________________________________________________
8) Are you active or do you exercise regularly or participate in a sport? If so, what kind and how often?
_____________________________________________________________
9) How has the past year been for you mentally, emotionally, and spiritually?
_____________________________________________________________
_____________________________________________________________
10) How would you describe your mental and emotional health during the last 4 - 12 months?
_____________________________________________________________
_____________________________________________________________
11) Is there anything else you wish me to know that may be relevant to your health and this consultation?
_____________________________________________________________
Health History
YES NO
____ ____ Are you pregnant/trying to get pregnant?
____ ____ Have you ever had any broken bones?
____ ____ Do you have a history of abuse?
____ ____ Have you ever had back problems?
____ ____ Do you wear contact lenses or glasses?
Have you (SELF) or a family member (FAM) ever been diagnosed with any of the following? Family
members include grandparents, mother, father, and siblings. Write “X” in column(s) where appropriate.
SELF FAM
____ ____ Allergies
____ ____ Cancer
____ ____ Diabetes
____ ____ Cancer
____ ____ Diabetes
____ ____ Elevated cholesterol
____ ____ Heart disease
____ ____ High blood pressure
____ ____ HIV
____ ____ Migraines
____ ____ Multiple Sclerosis
____ ____ Osteoporosis
____ ____ Parkinson’s
____ ____ Sexually transmitted disease
____ ____ Seizures
____ ____ Stroke
____ ____ Thyroid disease
____ ____ Other: Describe______________
By signing this form I give my consent and authorize Lawrence Birch CCH to review the information in his possession for the purposes of completing my "constitutional review." I agree not to take any legal action against Lawrence Birch CCH, GivingTree Farm Herb Company or any of its agents or employees for any reason whatsoever. I also give my consent for Lawrence Birch CCH to confidentially discuss my information with another health care practitioner if he deems it necessary. Furthermore, I authorize Lawrence Birch CCH to contact my own health care practitioner(s) if necessary. I further understand that any information shared with me is just that, information not medical or other advice. Healing is ultimately my responsibility.
Print Name: ________________________________________________________________ Date: ___________
Signature: _______________________________ Emergency contact name & phone #: _____________________
