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Stirred Water Herbs Client Questionnaire www.stirredwater.com 307 Old S Durham Hwy Acra, NY 12405 518-622-9383 This questionnaire is to help you and I understand your health concerns. If you prefer not to answer any questions do not mark them. You are not obligated to complete this form. Name: Date: Address: Phone: E-mail: Date of Birth: Age: Male/Female Height Weight Relationship Status Children: Occupation: Please check the types of health care practioners you have seen or are seeing. Chiropractor Naturopath Psychiatrist Other Counseling Massage therapist Psychologist Social Worker Herbalist Medical doctor Occupational Homeopath (type) Therapist

Main Reason for this visit (medical diagnoses, main complaints and symptoms): Other health issues: Current Medications and Treatments: Previous Medications and Treatments: Do you exercise? How often: Hospitalization Have you been hospitalized? When? Why? Surgeries What For? Why?

Health History ADD or ADHD Epilepsy Male health problems AIDS Epstein-Barr Virus Memory loss Alcoholism Excess Stress Menopause Problems Allergies Eyesight problems Menstrual irregularities Anemia Fatigue Numbness Anxiety Gynecological Problems Painful joints Arthritis Headaches Rashes Asthma Hearing Problems Respiratory Problems Bloating Heart Disease Seizures Cancer Hepatitis A, B or C Shingles Chemical Sensitivities High Blood Pressure Shortness of Breath Chronic Fatigue HIV Sleep Problems Common Cold (frequent) Sore throats (frequent) Constipation Hyperglycemia Stiffness Diabetes I or II Hypoglycemia Stomach Aches Diarrhea Immune disorders Swelling Dizziness Injuries Tumors Drug Abuse Low blood pressure Urinary tract infections

Environmental sensitivities other Childhood diseases and illness Allergies Chicken pox Mononucleosis Whooping cough Asthma German measles Mumps (Pertussis) Atopic eczema (Rubella) Rheumatic fever Bronchitis Measles Tonsillitis Family History Cancer High blood pressure Diabetes I or II Other Heart disease Low blood pressure Other Have you used medical or recreational drugs in your past? Which ones? Cardiovascular Health Angina Chest pains Heart attack Palpitation Arrhythmias Congenital deformities (myocardial infarction) Poor Circulation Arteriosclerosis Congestive heart failure Heart flutter Rheumatic fever Black and Blue Edema Heart irregularities Slow heart beat Easily Fast heart beat Heart murmur Stroke Capillary fragility High blood pressure Low blood pressure Varicose veins Cardiac arrest Mitral valve prolapsed Other Resting pulse rate Blood pressure (avg.) Cholesterol Do you have headaches? How long have you had them? Headache triggers? Seasonal Headaches? Time of the month of headaches?

Headache pain 1 to 10 Other symptoms with headaches? Medicines used or treatments tried for headaches and how they worked? Ears Ear infections Overly sensitive Other Earaches Hearing loss Tinnitus/Ringing Wax build-up Digestion Anorexia nervosa Dysentery Irritable bowel syndrome Stomach aches Belching Eating Disorders syndrome Sudden Weight change Bulimia Flatulence Large appetite Ulcer Changes in bowel habits Food unappetizing Liver problems Ulcerative Colitis Crohn s disease Gallstones Low appetite Vomiting Constipation Heartburn Nausea Other Diarrhea Hemorrhoid Pain after eating Diverticulitis Indigestion Parasites Bowel Movements How often? How many times a day? Is it difficult to go? How soon after a meal?

Immune System Allergies Hashimoto s Lowered resistance sick often Autoimmune disorders (thyroiditis) Lupus Sore throats Catch everything Heal slowly Mononucleosis Swollen lymph Chronic fatigue Immunodeficiency Rheumatoid White blood cell Enlarged spleen Infections arthritis count Cortisol Deficiency Difficulty getting up in the morning tired around 9pm Lightheaded when standing Acne second wind around 11 Men hair loss front of leg Not feeling rested Brown spots on face Debilitating fatigue Foggy thinking Thin and or dry skin Unstable blood sugar Low blood sugar Intolerance to exercise Weight gain-waist Decreased muscle mass Sleep disturbances Anxious /Nervousness Menstrual cycles heavier in beginning but decrease by day 3 Lack of mental focus, decreased productivity Feeling that everything is too hard Memory Lapses Depression Heart palpitations Headaches

Hair loss Sugar Cravings Salt cravings Allergies Chemical Sensitivities Aches and Pains Stress Cold Body Temperatures Extra nap revives Irritable Struggle to get through day but evening meal helps When is your highest and lowest energy level of the day? Have your energy levels changed at any point and did something trigger the change? Thyroid Function Tired all day Slow pulse rate Decreased muscle mass Always feeling hot Depressed Decreased sweating Thinning skin Bulging eyes Cold body temp. Hair loss Infertility problems Erratic behavior Cold hands/feet Hair dry or brittle Slowed reflexes Irritable weight gain Nails breaking or brittle Constipation Panic attacks Can t lose weight Aches and pains Thick tongue Decreased concentration Memory lapses Decreased libido Low blood pressure Short attention span High cholesterol bone loss Rapid weight loss Rapid heartbeat Mood changes Heart palpitations Insomnia Goiter Swelling/puffy Sleep disturbances Unusual sweating Tremor in fingers Eyes or face Nervous Prefer coffee or sugary foods eyebrow loss Hit wall 9pm no second wind extra sleep doesn t help

Sleep Fall asleep fast Wake often Stay awake till 11pm Sleep through the night Wake to urinate Stay awake till 1am Hard to fall asleep, but Restless sleep Wake up at 3 am Stay asleep Restful sleep Hard to fall and stay asleep Dreams: (circle) Active, lucid, anxious, nightmares, probing, pleasant, scary. How many hours do you sleep? How many hours do you need to sleep to feel rested? Do you feel rested in the morning when you wake up? Allergies Do you have allergies? What are they? When do your allergies act up? Do you have allergic reactions to any drugs or herbal medicines? What has helped your allergies?

Respiratory Asthma Hay fever Tight around lungs Bronchitis Chest pain Common Cold Coughing Difficulty smelling Flu Fluid in lungs Laryngitis Pleuritis Respiratory Runny nose Shortness of breath Sneezing Inflammation stuffy nose trouble breathing in trouble breathing out wheezing tuberculosis Other Which season is the congestion worse and best? Do you know foods, environmental factors or situations that affect your breathing? Urinary Tract Bloating Kidney/bladder stones Urinary tract infections Blood in urine Kidney pain Water retention Burning urination Lower back pain Frequent urge to urinate Strong smelling urine

How many times a day do you urinate? Do you wake up to urinate at night? How many times? Is it difficult to urinate? Do you have frequent infections? When you urinate do you still feel like you have to go? DIET What do you drink most frequently and how much? What are your favorite foods that you eat often? Give an example of your daily diet:

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