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Medical History. Select all that apply

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Overall Energy of the Body: severe pain in chest or abdomen Racing pulse Eczema or skin rash Painful sore muscle Offensive fecal odor constipation Apple or beer belly obesity Abdominal tension bloated Bright eyes strong voice Normal skin color Tight skin Slow pulse (less than 50 beats per minute) Loose abdominal muscles Dull eyes weak voice Pale skin Sweating without physical exertion stomach rumblings or gurgling Sweating at night No constipation no odor of feces Loose skin Hernia or prolapse organs

Would you describe your present physical-emotional state as;

My physical well being

strong and robust

beginning to be worn down

adversely affects

Physically weary

Physically exhausted

My emotional well-being

not affected

beginning to affect

adversely affects

emotional tired

emotional exhausted

physically and emotionally no problem just need a little bit of help

Deficiency of the Body's Energy (Qi Xu) Easy fatigue after exercise Daytime sleepiness feet Frequent infection Jelly / beer belly or reduced tension in lower abdomen Feeble voice Frequent diarrhea Collapsed organs (weak bladder hemorrhoids hernia prolapsed uterus) Loss of appetite Easily frightened Lack of willpower Slow pulse without athletic training Flabby muscles, lack of strength General fatigue sensitivity to cold Swelling water retention or sweaty palms or

Stagnation of the Body's Energy (Qi Stasis) Depression Difficult getting out of bed in the morning Heavy feeling in the head as if wearing hat Bloating, gas Stomach rumbling Feeling of incomplete urination Qi Rebellion 3 Lump in the throat Chest Cold, Stuffy, Asthma or emptiness Pain or distention is the sides of the chest Pain that drifts through the body frequent flatulence or gas Hiccups

Abdominal palpitations Coughing attacks irritability Racing heart for no apparent reason Vomiting Painful spasms in the abdomen Cold hands and feet Gluten intolerance

Red Face Impatience Recurrent headaches Easily frightened Sweaty hands and feet Upper part of the body Hot while Lower part Cold Milk Intolerance

Fluids Affecting the Body Edema of the whole body Edema of hands, body and face only Edema of the abdomen only Edema of the legs and ankles only Glands, Swollen, painful Fluid Any Edema Excessive urination Dizziness Congestive heart failure Stiff joints in the morning Passing out / Dizzy when rising from seated position 4 Thirst for ice cold drinks mouth is dry Thirsty but only sip Not Thirsty, balanced taste in mouth Thirst and drinking followed by vomiting

Motion sickness Palpitations above umbilicus Throbbing headache Nausea, vomiting Runny nose Sore or painful Low back better with warmth and touch Condition of the Blood Dry or rough skin Pale complexion Eyesight Decreased visual acuity at night Insomnia Symptoms worse at night Hair loss Broken, brittle or dry nails Dizziness Muscular weakness Lumps Fixed, that are painful

Watery diarrhea Frequent urination Foamy saliva Feeling of heaviness Drooling Pain Non-traumatic joint or muscle pain

Painful joints and muscles which may be swollen but are not red or hot to the touch. The pain feels

Loss of tactile sensation in the skin Red gums Red tongue Red lips Hemorrhoids Tenderness on the left side of the navel Tenderness on the right side of the navel Tenderness on the sides below the rib cage Tenderness on the lower abdomen Pain Fixed, sharp, and/or severe Facial freckles Dark circles under the eyes Rash on the palms 5

Spider veins , varicosities, mole-like hemangiomas Scanty or missed menstrual periods Menstruate Blood clots

Muscle cramps recently or am presently used an enema or bowel cleansing Colonic / Colon Cleanse recently took a steam bath or sauna recently exercised or worked-out vigorously producing a sweat recently would shower and go outside immediately after

These last few questions are critical to determining the correct TCM treatment protocol specific to your condition. Please answer as best you can, adding any comments or explanations in the comments section below.

Menstruation I am not on the pill

I am pregnant

I am on the pill I am trying to become pregnant

women

who stop using the pill after some years very often develop amenorrhea (lack of menstruation) or a very irregular-late cycle. This condition usually resolves within a few months of herbal therapy The Contraceptive Pill regularizes the periods and makes them scanty. An IUD makes the periods heavier or more painful. If you are on either please refer to your cycle prior before use.

Menstrual Cycle TCM considers 28 days normal, however I consider the regularity and consistency of the cycle to be more important NOTE: Hold Down Ctrl while clicking with the mouse to select more than one response.

Amount

Color During normal menstrual the blood varies from dark-red red in the middle and pinkish at the end.

lighter in the beginning, deep

Consistency Normal flow is smooth without clots, neither thin or thick

Bowel Movements (Constipation / Diarrhea, loose stools)

Urination (click all that apply)

Please select all that apply Hold Down Ctrl while clicking with the mouse to select more than one response.

My present complaint began

Do you have severe apophylaxis cirrhosis/ liver dysfunction /chronic hepatitis with a platelet count of l50,000/mn 3 or below Are you presently taking any of these Preparations containing Glycyrrhiza Preparations containing glvcvrrhizinic acid or glvcyrrhizinates Loop diuretics Furosemide Etacrynic acid Thiazidic diuretics, Trichlomethiazide Interferon Preparations Preparations containing Ephedrine Preparations containing ephedrine-related compounds 9

Monoamine oxidase (MAO) inhibitors Thxroid preparations (such as thyroxine, liothyronine) Catecholamine preparations epinephrine isoprenaline Xanthine preparations (such as theophyllinc. diprophylline) Please describe your TONGUE color condition describe your pulse (heart rate)

additional comments: use of Alcohol, Stimulants, Recreational Dugs. How the weather affects you or your condition. And what would you like us to do for you.

Lastly, we will search our database of 5,300 herbal products in 34 product lines to provide the best herbal prescription for you. preferences Do you prefer capsules granules liquid extract or non-alcohol

Do you have a favorite product line

leave the choice to the happyherbalist

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Submit

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There is no charge or fees for this service:

diagnosis@HappyHerbalist.com

We will return your diagnosis via email with a herbal recommendation. You may be able to purchase the herbal formula locally or online. In many cases this may help you to make an informed choice regarding your health. And may prove useful in deliberations with your local health care practitioner. In some cases it may be necessary to have a office visit where a more complete diagnosis and treatment can be made. Completing this form we believe will help the process along quickly and efficiency. Please remember this is not a western diagnosis of a medical disease. It is a Traditional Chinese Medicinal approach treating disorders of the Yin and Yang, Qi, Blood and Fluids with herbs and where necessary in the office with acupuncture. To Your Health,

Ed Kasper LAc
California licensed Acupuncturist & Herbalist. A primary care provider. the Happy Herbalist, combining and creating people friendly botanicals.

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