Dragonfly Integrative Health Intake Form

Dragonfly Integrative Health Intake Form

46 Lottsdr

Windham, Maine

207-619-2414

Name:Today’s date:

Address:

Phone number: Email:

Birthdate: Weight: Height: Male/Female:

Occupation: Enjoy your job:

Relationship status: Date of last physical:

Share home with:

Do you have children, if yes ages?

Practitioners:

Are you currently under the care of a health care practitioner? Please note which of the following types of health care practitioners you have seen. Use P if you have seen them in the past and use C if you are currently under their care.

____Ayurvedic Practitioner, ____ Naturopath, ____ Psychiatrist, ____Psychologist, ____Chiropractor

____ Social Worker, ____ Medical Doctor, type (____). ____Massage Therapist, ____Spiritual Counselor

____Counseling, ____ Herbalist, ____ Homeopath, ____ Occupational Therapist, ____ Traditional

____Physical Therapist Chinese Medicine, ____Bodywork type______

Other______

Daily Medications, vitamins, herbs with current dosing and recreational drugs;

______

Any reason on why you can’t take extracts made in alcohol? Y , N , if Y reason: ______

Family History immediate family only:

Hypertension or Hypotension: ______

Arthritis or RH: ______

Depression, anxiety, or mental illnesses: ______

Asthma or Emphysema: ______

Liver disease: ______

Ulcers:______

Diabetes, metabolic disorders: ______

Kidney or bladder problems: ______

Thyroid imbalances: ______

Cancer:______

Auto Immune Disorders:______

Menstrual or pregnancy difficulties: ______

Tuberculosis: ______

Main reason for visit, time frame on when symptoms started:______

Anything change recently in your life: Y N if Yes explain: ______

Hospitalizations, circumstances, length of stay, treatments: ______

______

______

Surgery’s and when:______

______

Are you under a medical providers care and or diagnosed with:

__ Aids __ Arthritis (Rheumatoid)__ Arthritis (Osteo)

__ Arrhythmia __ ADD/ADHD__ BPH

__ Autoimmune Disorder (Specify; ) ___Bipolar/manic disorder

__ Bleeding Disorder__Cancer (Specify; )

__Heart attack__ Celiac Disease__COPD (chronic obstructive pulmonary disorder)

__ Cirrhosis of the liver__ Colitis __ Depression

__ CHF (congestive heart failure)__ Diabetes__ Eczema

__ Endometriosis__Angina__ Asthma

__Celica Disease__ Epilepsy__ Fatty Liver Disease

__Fibromyalgia__ Graves’ Disease __Hahsimoto’s Disease

__Hepatitis__IBS/Chrohns/Colitis__Kidney stones

__ Hypothyroidism __Lupus ___MS (multiple sclerosis

__ OCD (obsessive compulsive disorder)

__Psoriasis__Ulcers__EBV (mono)

__Lyme (specify; )

How many hours of sleep do you get: ______How do you sleep: ______

______

How much water do you drink in a day: ______

Caffeine in a day and what kind: ______

How often do you exercise, how long and what do you do? ______

______

How often do you eliminate bowels? ______

Do you smoke cigarettes, cigars, chew, recreational drugs:______

Relaxation programs; ______

Circle 2 dominant emotions in your life;

Joy, Anger, Fear, Grief, Happiness, Sympathy, Anxiety, Sadness, Peace

Have you had any of the following childhood disease:

_____Chicken pox ____ German Measles (rubella) ____ Measles

____ Mumps _____ Rheumatic fever _____Pertussis (whooping cough) _____Recurrent strep infections

_____ Other

Symptoms

Digestive. Liver and Intestinal Symptoms: Check all that apply.

___Abdominal pain or discomfort___ Acid Indigestion, heartburn, acid reflux

___ Bad breath___ Bloating, belching or intestinal gas

___ Constipation (less than 1 BM a day)___ Cravings for sugary foods

___ Diarrhea or loose stool___ Food allergies, which foods;

___Food sits heavy on stomach after meals ___ Groggy feeling in morning

___ Hard, dry stools___Hemorrhoids

___ Loss of appetite or poor appetite___ Loss of smell or taste

___ Sensation of lump in throat___ Stomachaches

___ Under weight, unable to gain

Respiratory. Check all that apply.

___ Chronic or frequent cough___ Cold sores

___ Excess mucous production___ Frequent infections

___ Hay fever and respiratory allergies___Itchy nose or ears

___ Post nasal drip___ Sinus headaches

___ Chronic sinus congestion___ Wheezing or shortness of breath

Circulatory. Check all that apply.

___Anemia___Chest pain

___ Cold hands and feet___ Family history or heart disease

___ Gingivitis or gum disease___ Heart palpitations

___ Hypertension or hypotension___ Hyperlipidemia

___High Triglycerides____ arrhythmia

___ tachycardia (rapid heart rate)___ Swelling in lower extremities

___ Varicose or spider veins___ Wounds that won’t heal

Urinary and Fluid System. Check all that apply.

___ Bladder infections___ Hematuria (blood in urine)

___ Dysuria (painful urination) ___ Difficulty starting urination

___ Excessive perspiration___ Frequent pale urine

___ Frequent urination___ Kidney stones

___ Night sweats___ Pain in mid to low back

___ Puffiness under eyes ___ Scant, dark urine

___ UTI’s ___Edema (water retention)

___Swollen lymph nodes

Males only. Check all that apply.

___ Difficulty urinating___ Erectile dysfunction

___ Infertility___ Decreased libido

___ Loss of self-confidence and drive___ Nighttime urination

___ Prostate problems

Female only. Check all that apply

___ Cravings for chocolate with periods___ Depression with periods

___Nursing (currently)___ Edema or bloating w/ periods

___ Heavy menstrual bleeding___ Hot flashes/ night flashes

___ Infertility ___ Irritability w/ periods

___ Decreased Libido___ Menstrual cramps

___ Post menopausal___Pregnant (currently)

___ Vaginal discharge___ Vaginal dryness

Nervous System. Check all that apply

___ Absent-mindedness___ Alcoholism

___ Anxiety, nervousness___ Chronic muscle tension

___ Difficulty getting to sleep___ Light headedness, dizziness

___ Difficultly relaxing___ Feeling depressed

___ Headaches___Tension headaches w/ tight constricted feeling

___ Pounding headaches___ Headaches around eyes or forehead

___ Migraines___ Loss of memory

___Panic attacks___Peripheral neuropathy

___ Poor concentration___Shaky hands

Structural System. Check all that apply.

___ Acne___ Arthritis

___ Backpain___Brittle fingernails

___ Eczema___ Gout

___Itching of the skin___ Joint pain/___leg cramps/___muscle cramps

___ Multiple root canals___ Neck pain

___ Osteoporosis___ Rashes

___Rosacea___ teeth grinding

___ weak legs, knees or ankles

Glandular System. Check all that apply.

___ Burning sensation in hands and feet___ Dark circles under eyes

___ Dry skin___ Excess weight

___ Excess weight around the abdomen___ Fatigue in the afternoon

___ Fatigue, chronic___Feeling exhausted “burnt out”

___ Frequent thirst___ Hair loss or thinning

___ Lack of stamina___ Loss of short term memory

___ Low body temperature easily chilled___ Mental sluggishness “Brain fog”

___Mood swings___ confusion

___ restless disturbed sleep___ Waking up at night unable to go back to sleep

Describe a typical day.

Breakfast / Lunch / Dinner / Snack

Estimate how many servings you eat of the following in per day

Read Meat / Green vegetables / Oils / Coffee
Poultry / Fish / Beans/legumes / Soy products
Vegetable proteins / Yelloe vegetables / Fruit / Milk/yogurt
Cheese / Butter / Wheat / Whole grains
Pastries/sweets / Chocolate / Tea / Alcohol
Herbal tea / Dining out

If you could change anything about your eating habits what would it be? ______

Is there anything else that wasn’t in this intake that you would like to share? ______

Dragonfly Integrative Health Intake Form

46 Lottsdr

Windham, Maine

207-619-2414

Waiver of Liability;

Clients are reminded that it is their personal right and responsibility to make educated choices in their own and their family’s health care. Dragonfly Integrative Health does not make these choices for the client but provides educational resources in the historic and traditional use of herbs.

I thoroughly understand that only a physician (MD, DO) can diagnose, treat and prescribe medicines for illness. The role of the herbalist in any healing process is not to consider a client’s individual system but to consider a client as a whole person and to consult the client concerning lifestyle, diet and herbal recommendations with always listening to the client.

I, undersigned, understand the above paragraph, and release Dragonfly Integrative Health and all associates of this business from any liability. I also confirm that I am consulting with this names individual of Dragonfly Integrative Health on my own free will. I understand that there will be no diagnosis made, or prescription given, but that an assessment of my general health will be made with lifestyle, dietary, and herbal recommendations.

Date: ______

Client Signature:______

Herbalist signature:______

Date:______