Personal Health Profile. Address:

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1 1 P age Personal Health Profile Initials: Personal Health Profile Name: Address: Date: Phone Numbers: Home: Work: Fax: E- mail: Date of Birth: Age: Weight: Height: Blood Type: Occupation: Relationship Status: Partner s Name: Partner s Occupation: Religious Affiliation/Spiritual Practices: Name(s) and Age(s) of Children: Medications Foods Environmental ALLERGIES (include type of reaction) Please list any medications taken regularly, including prescription, recreational or over- the- counter: Please list any vitamins, minerals, or herbal supplements taken regularly: Physician s Diagnosis: Physician s Treatment: Present Health Concerns: (The reason for today s visit) How long have you had it? Have you had it before? yes no Is it getting worse? yes no What makes it better? What makes it worse? What are you doing for it? Other Practitioner s Response: Whole Body Health: Circle the following that is true: Do you run hot or cold? Do you prefer to warm up or cool off? Are you the most comfortable in the Summer or Winter? Spring or Fall? Are you the first person to put on a jacket? yes no Do you tend to be warm at night and cold in the day time? yes no Do you sweat easily? yes no Do you have an appetite for food? yes no Do you have cravings for meat, sugar, salt, sour, bitter? (circle one) Do you experience thirst? yes no Comment: How do you feel after you eat? (within the hour) bloated nausea crampy tired gassy

2 2 P age Personal Health Profile Initials: Food Use Frequency Food Category Never Sometimes Often Comments Animal Protein (Beef, Pork, Eggs,etc.) Dairy (Milk, Cheese, Yogurt) Fried Foods Sugar Alcohol Coffee/Caffeine Soda Artificial Sweeteners Tobacco Soy Products Water Type of Oils Used Snack Habits: Bowel and Bladder Do you feel you urinate too frequently for what you drink? yes no Do you wake up at night to urinate? yes no If you answered Yes, how often? How often do you have a bowel movement? Energy: Do you have enough energy to do what you want to do? yes no Do you have high points and/or low points in the day? yes no If answered yes, explain: Do you crash in the afternoon? yes no Do you have brain fog? yes no If Yes, for how long? What time do you usually go to bed? Do you have problems getting to sleep? yes no Do you have problems staying asleep? yes no When do you usually wake up? Do you wake up feeling rested? yes no Do you experience night terrors? yes no Past Medical History Please list any operations you have had along with dates. (Include appendectomy, tonsillectomy, etc.) Please list any major injuries/accidents, including dates: Please list any traumatic experiences not treated medically (divorce, loss of lover, loss of job, death of loved one, etc.): Family Medical History Maternal Medical History: Paternal Medical History: Sibling Medical History: Are you or any family member in a recovery program? If yes, which one? Common Physical Activities Please list: _

3 3 P age Personal Health Profile Initials: Please write a diary of your meals on a typical day: Breakfast: Diet Lunch: Dinner: Body System Health Profile Please check any item listed below, rating it as follows: 1 = sometimes 2 = often 3 = major concern Eyes, Ears, Nose & Throat Skin Eye pain, wet/dry Failing vision Earaches Hearing Loss Ringing in the ears/tinnitus Hay Fever Tonsils Feeling of something stuck in throat Other: Digestive Mouth ulcers Halitosis bad breath Hiatal hernia Bloating History of Hepatitis Gall Stones Hypoglycemia (low blood sugar) Indigestion Ulcers Constipation Diarrhea Irritable Bowel Syndrome Polyps Hemorrhoids Bleeding from Anus Flatulence Have you traveled abroad often? Yes No List where: Other: Musculo/Skeletal Difficulty Breathing Stiffness Bursitis Torn ligaments Backache: upper/lower Broken Bones: List: Arthritis Boils Acne Eczema Psoriasis Bruise Easily Herpes Simplex Slow Wound Healing Other: Circulatory High Blood Pressure Low Blood Pressure Palpitations High Cholesterol Triglycerides Varicose Veins Spider Veins Cold Hands and Feet Poor Circulation Pain in chest Previous Heart Attack/ Stroke Swelling in ankles/joints Other: Respiratory Allergies Asthma Sore Throat Sinusitis Post Nasal Drip Lung Congestion Cough History of Tuberculosis Recurrent influenza Colds Other:

4 4 P age Personal Health Profile Initials: Mobility Restriction Gout Sprains Other: Urinary Bladder infections (cystitis) Kidney Stones Water retention/swelling of ankles/legs Incontinence Painful urination Excessive urination Lower Back Pain Reproductive (Men) Impotence Sexually Transmitted Disease List type if known: Prostatitis Difficulty with urination Benign Prostatic Enlargement Premature Ejaculation Low Sperm count Low Sperm motility Other: Dark circles under the eyes Gout Other: Reproductive (Women) Pregnancies, Dates: Miscarriage Date: Abortion Date: Contraceptive Use: List type(s) & how long used: Sexually Transmitted Disease, List type if known: Hysterectomy, Date: Reason: Uterine fibroids Ovarian cyst Genital herpes Endometriosis Cervical dysplasia Vaginal infection Painful intercourse Breast Pain Anemia Breast Lump Vaginal itching/discharge Pelvic Inflammatory Disease Infertility Menstruating Women Menopausal Women Irregular menstrual cycles Heavy menstrual bleeding Painful menstrual cramps Bleeding between cycles Absence of menstrual cycles Dramatic mood swings around menstrual cycle Other: Endocrine Glands Pituitary Pineal Thyroid Hypothyroid Hyperthyroid Pancreas Diabetes (Please indicate type 1 or 2) Hypoglycemia Other: Hot flashes Dramatic mood swings Dry vaginal lining Osteoporosis Vaginal Bleeding Estrogen Replacement Therapy Other: Lymphatic Congestion Swollen glands Infection Drainage Other:

5 5 P age Personal Health Profile Initials: Nervous System Anxiety Irritability Stress Headaches Migraines Insomnia Depression Attention Deficit Hyperactivity Mental Sluggishness Irritation to strong light Shingles Other: Immune System Autoimmune disease Chronic Fatigue Syndrome Fibromyalgia Neuralgia Frequent colds Vaccinations Chronic Fatigue Syndrome Other: Staff Use Only Please Do Not Write Below This Line Blood Pressure: Tongue: Body: Coat: Features: Constitution Type Sys Action Evaluation Kappha GI Relaxation Pita Mus S Doing Vata Ner S Thinking Pulse Pos Left Right I Sm int Heart Lungs Colon II Gall Liver Spleen Stomach III Bladder Kid Yin Heart Protector Triple Heater NOTES: