( ) Sinusits ( ) OTHER: _____________________ I usually feel: Hot Cold Fever Chills □ □ □ □ Sweating: Inability Profuse Night sweats Spontaneous □ □ □ □ Half of body Left side Right side Upper body Lower body □ □ □ □ □ Head Chest Hands & Feet Armpit □ □ □ □ How would you rate your energy level on a scale of 1-10, with 10 being the highest: _____ How you rate your stress level on a scale of 1-10, with 10 being the highest: _____ How many hours of sleep do you get each night? ______________ Do you experience: Difficulty falling asleep Staying asleep Interrupted sleep Nightmares □ □ □ □ Vivid dreams Wake up not well-rested □ □ Level of physical activity? What and how frequent? __________________________________________________________________________ Do you do any of the following: Smoke Consume Alcohol Recreational drugs □ □ □ How often do you urinate throughout the day? ____________ Volume: Scanty Copious Normal □ □ □ Clear Yellow Cloudy □ □ □ Burning Dribbling Incontinence Dysuria □ □ □ □ High libido Low libido Normal □ □ □ How many bowel movements do you have in a day or week? ___________ Constipation Diarrhea Alternation between constipation/diarrhea □ □ □ Are your bowel movements: Well-formed Loose Small pebbles Easy to pass Sticky □ □ □ □ □ Dry/difficult to pass Urgent Mucus Undigested food Blood □ □ □ □ □
( ) Sinusits ( ) OTHER: _____________________ I usually feel: □ Hot □ Cold □ Fever □ Chills Sweating: □ Inability □ Profuse □ Night sweats □ Spontaneous □ Half of body □ Left side □ Right side □ Upper body □ Lower body □ Head □ Chest □ Hands & Feet □ Armpit How would you rate your energy level on a scale of 1-10, with 10 being the highest: _____ How you rate your stress level on a scale of 1-10, with 10 being the highest: _____ How many hours of sleep do you get each night? ______________ Do you experience: □ Difficulty falling asleep □ Staying asleep □ Interrupted sleep □ Nightmares □ Vivid dreams □ Wake up not well-rested Level of physical activity? What and how frequent? __________________________________________________________________________ Do you do any of the following: □ Smoke □ Consume Alcohol □ Recreational drugs How often do you urinate throughout the day? ____________ Volume: □ Scanty □ Copious □ Normal □ Clear □ Yellow □ Cloudy □ Burning □ Dribbling □ Incontinence □ Dysuria □ High libido □ Low libido □ Normal How many bowel movements do you have in a day or week? ___________ □ Constipation □ Diarrhea □ Alternation between constipation/diarrhea Are your bowel movements: □ Well-formed □ Loose □ Small pebbles □ Easy to pass □ Sticky □ Dry/difficult to pass □ Urgent □ Mucus □ Undigested food □ Blood
Client-Intake-Form-Honey-Ginger-1.docx