CHINESE MEDICINE ASSESSMENT FORM INTAKE FORMPlease fill out all forms below so that the master herbalist can do a superior assessment on your behalf. Every item is important in order to prepare a comprehensive assessment that defines the key underlying conditions. When answering questions, you may notice repetitive questions. There is a reason for this. It is not an error. This form cannot be processed over the phone. Please use a laptop, computer, or tablet only. We are working to correct this soon!The assessment will help determine the correct herb formula(s), diet, and lifestyle recommendations for quick resolution of:immediate concernslong-term imbalancespotential worsening conditionsOnce completed, click the Submit button below and the assessment will automatically be sent to the senior herbalist, Mark Hammer CMH-III.PDF Form Available: If you prefer, you can download the assessment form as a PDF here.. Fill out and email it back to herbmaster@traditional-chinese-herbs.com . All communication is protected and absolutely confidential. Process: The herbalist usually needs a day to review and assess. He will then call you to set up a time to discuss his findings with you. You can always call in if you have questions. You will always have final determination with regards to your regimen since that is the reality-your success is dependent on you with a lot of support from your herb medicine practitioner.NameEmailDate of BirthAgeSexMaleFemaleHeight (ft./inch)Weight (lbs)Marital StatusSingleMarriedDivorcedOtherProfessionReferral SourceBlood PressurePulseTemperatureCholesterolTriglyceridesMedicationsPast OperationsPlease click on all conditions that are relevant to you in Parts A-H, etc. and fill in text areas to clarify the condition, as needed.In your own words describe your chief complaint(s).PATIENT CONDITION INFORMATIONPart A. Please check any symptoms that apply to you now or in the last 3 months. cough wheezing hoarseness loss of smell nasal discharge allergies itching eyes acne itchy skin vocal problems painful lymph nodes dry brittle hair fatigues after perspiring grief crave spicy foods dislike wind phlegm short of breath sneezing nasal congestion asthma hay fever sinus headaches perspire easily swollen glands sore throats dry skin smoker catch colds easily melancholy- sadness dislike dry weather dislike damp weatherPart B drooping eyelid prolapsed stomach nose bleeds loose stool stomach pain intestinal rumbling butterfly sensation in stomach poor short term memory inability to concentrate crave sweets cookies - cakes slow wound healing abdominal bloating discomfort after eating vomiting flatulence hernia prolapsed uterus gums bleed easily diarrhea heartburn ulcers gas alternating constipation & diarrhea bad breath poor long term memory loss of taste chocolate especially bruise easily poor digestion fatigue after eating nausea belching - burping hemorrhoidsBowel movements per dayKnown food allergiesAppetiteHighLowModeratePart C headache tight or constricted chest pains increase with stress high blood pressure vertigo yellow eyes/skin hiccups lower rib pain depression sensation of something in throat eyes tired blurred vision high cholesterol history of hepatitis migraine anger easily clear throat often acid regurgitation eyes red spots before eyes irritable bitter taste in mouth frustration dizziness eyes sensitive eyes sore high triglyceridesHeadache (where in the head)Part D. Women Only painful menses irregular cycle cramps later in flow history of vaginal warts irregular pap test breasts painful fibrocystic breast/ovary infertility regular breast exam or mammogram cycle (ie. every 28 days) clots recent change in cycle vaginal pain breast distension fibroid tumors cramps early in flow date of last periodPremenstrual symptoms (describe)Age of menopauseColor of flowDarkLightClearMiscarriagesDate of last periodAge at first periodLength of flow# of pregnancyGyn surgeriesPart E fatigue cold feet urination daily decreased stream or amount painful urination low dark circles rheumatoid arthritis impotence intolerant of cold joints stiff fear morning diarrhea incontinence burning/painful urination puffy beneath eyes loss teeth infertility abnormal thirst history of kidney stones pains get worse with exercise asthma memory loss awakens fatigued cold hands night urination urgent urination high hearing loss weak/sore knees hair loss chronic urinary infections history if Kidney infection difficulty breathing anxiety excess energy difficult urination swelling ankles lower back pain osteoarthritis spermatorrhea craves salt joints painful phobias seminal emissionUrine colorDarkLightClearEar ringingHighLowSlump time of daySex driveHighLowNormalPart F speech problems jittery hot palms pale skin feeling of impending doom chest pain irritability flushing in afternoon sore tongue heart murmur scanty, yellow urine Palpitations (feeling of heart beating, racing, or skipping beats) delirium sweat at night insomnia missed pulse beats dry mouth restlessness short of breath numb hands mouth sores chest congested racing heart beatPart G sense of heaviness favorite color muscle cramps brittle nails sedentary work twitches/spasms favor warm drinks physical labor fever/chills favors cold drinks regular exercise weaknessPart H (medication) Antacids Antibiotic/Antifungal Anti-inflammatory Chemotherapy High Blood Pressure Rx Laxatives Radiation Thyroid Ulcer Medications Antidepressants Glucose Regulator/Insulin Aspirin/Tylenol/Advil Heart Medications Hormones Oral Contraceptives Recreational Drugs Relaxants/Sleeping PillsOther Meds Do You Eat, Drink or Use Alcohol Coffee Decaf Candy Cigarettes Carbonated Beverages Diet Sodas Distilled Water Fried Foods Fast foods, regularly Refined sugars Red meat, regularly Margarine Vitamins Minerals Herbs HomeopathicsCheck if you diet often salt foods w/o tasting exposed to chemicals exercise are under excessive stress work at a computerCheck any you have had appendicitis typhoid fever Rheumatic fever malaria mumps small pox diabetes heart disease polio hearing loss herpes hepatitis obesity cancer goiter pleurisy chemical poisoning allergic reaction alcoholism eating disorders scarlet fever HIV nephritis anemia measles eczema diptheria pneumonia jaundice tuberculosis tonsillectomy epilepsy asthma heart attack influenza meningitis drug reaction whooping cough mental disorders venereal infectionAnything else you would like us to be aware of?Family History of: (list who) StrokeHeart DiseaseCancer (who & what kinds)DiabetesMental DisorderGallbladder Disease Thyroid DiseaseAlzheimer'sNeurologic DiseaseEmotional Status-Depression (click item indicating your how you feel usually) 1 (Mild Depression) 2 3 (Moderate Depression) 4 5 (Severe Depression)Emotional Status-Anxiety (click on item indicating your how you feel usually) 1 (Mild Anxiety) 2 3 (Moderate Anxiety) 4 5 (Severe Anxiety) CURRENT DIETPlease provide what a typical day would like. Record all the foods you eat and drink. Be sure to include the approximate amount of each food. When you have completed this booklet, return it to your healthcare practitioner for evaluation. Your diet may be the key to better health. BreakfastMorning SnackLunchDinnerEvening Snack CONSTITUTION ASSESSMENT SECTION Scoring: Give yourself:0 point for no condition exists (0 events per month) 1 point for mild symptoms (1-2 events per month) 2 points for moderate symptoms (3-6 events per month) 3 points for a severe condition (7 events+ per month) If a condition doesn’t apply then leave the item blank. Men and women: Fill out both Yin and Yang sections below. For unclear items, consult your Traditional Chinese Medicine practitioner.YIN CONSTITUTION 1. Give yourself two Yin points, if you are a woman01232. Do you predominantly have feminine characteristics? (Men incl.)01233. Do you appear timid?01234. Do you stay indoors?01235. Easily tired? (tired from walking around the block)01236. Are you predominantly sluggish in your behavior?01237. Easily fall asleep when traveling by plane, train, or bus?01238. Are you more comfortable in winter-cold compared to summer-heat?01239. Overweight? (If yes, score 1 point for every 10 lbs. over normal weight for your sex & build. If over 30 lbs, then click 3-Critical.012310. Is food more than or just as appealing as sex? (libido question)012311. Is your sex drive weaker than normal (1=1 interruption/mth., 2=2-4 episodes/mth. 3=no function)0123YIN: COLD CONSTITUTION1. Is your thirst usually quenched?01232. Do you like hot drinks more than cold drinks?01233. Do you normally have a pale complexion?01234. Is your urine usually plentiful and clear?01235. Bowel movements are normally soft?01236. Do you often have cold hands or feet? (1=sometimes, 3=always)01237. During cold weather do you experience muscular or joint pain?01238. Is the skin surface of your stomach, cool or cold? 0123YIN: DAMP CONSTITUTION1. Do you often feel tired?01232. Are you overweight? (1=10 lbs., 2=20 lbs., 3=30 lbs.+)01233. Is your complexion usually dull?01234. Are you often sad or depressed?01235. Do your palms sweat?01236. Is your tongue usually glossy or greasy?01237. Do your joints ache when its raining?01238. Does your tongue have indentations on the side? (Look in mirror)0123YIN: DEFICIENT CONSTITUTION1. Do you drink fluids throughout the day?01232. Are you often tired but appear to have abundant energy?01233. Are you skinny or underweight?01234. Do you sweat a lot?01235. Do you sometimes suffer from heart palpitations?01236. Is your tongue white or light pink without coating?01237. Do you experience (insomnia, irritability, worry, excess thought) 0123YANG CONSTITUTION*Men and women: Fill out both Yin and Yang sections.1. If you are a man, give yourself 2 Yang points.01232. Do you consider yourself masculine?01233. Are you generally self-confident?01234. Are you the outdoor type?01235. Can you work for long stints without tiring?01236. Do you consider yourself energetic?01237. Do you find it difficult to sleep when traveling by plane, train, or bus?01238. Are your hands often hot?01239. Do your feet sweat?012310. Do you prefer the heat of summer to the cold of winter?012311. Are you underweight? (Score 1 point for 10 lbs. below the normal weight for your sex and build, 2=20 lbs., 3=30+ lbs.)012312. Do you consider your sex drive to be higher than normal? (Give yourself: 1 point: responsive, 2 point: strong and 3 points: very strong.)0123YANG: HOT CONSTITUTION1. Do you normally prefer cold drinks over warm or hot ones?01232. Is your complexion generally reddish?01233. Is your urine usually scanty and of a reddish or yellowish hue?01234. Are you often constipated? (Score: 1 for 1 time per wk., 2 for 2 times per wk., 3 for 3 times +)01235. Are your stools usually dry?01236. Is your tongue normally red with a yellowish coating or no coating? (Look in the mirror)01237. Do you suffer from frequent skin eruptions or sores?01238. Do you stay up past 12 midnight? (1=hr., 2=2 hrs., 3=3+ hrs.)0123YANG: DRY CONSTITUTION1. Are you often thirsty?01232. Are your nose & throat usually dry?01233. When you catch cold, is your cough usually dry without mucus?01234. Do your eyes and nose often itch?01235. Is your tongue frequently parched and dry?01236. Is it difficult for you to gain weight?01237. Are you often constipated? (Score: 1 for 1 time per wk., 2 for 2 times per wk., 3 for 3 times +)01238. Is your skin usually dry?0123YANG: EXCESSIVE CONSTITUTION1. Are you usually full of energy? (always moving or doing things)01232. Do you consider yourself to be normally high-spirited?01233. Is the tone of your voice high-pitched?01234. Is your complexion usually flushed?01235. Is your blood pressure higher than normal? (1=10 pts higher, 2=20 pts higher or 3=30pts+ higher)01236. Are you restless and impatient?01237. Do you suffer from constipation? (Score: 1 for 1 time per wk., 2 for 2 times per wk., 3 for 3 times +)01238. Do you have any acid regurgitation, reflux, GERD, or hiatal hernia?0123Emotion: What emotion(s) do you experience most in your life? Anxiety Grief Depression Sadness Anger Worry Rage Joy Fear HyperDid you get COVID?How many hours do you sleep at night (average)?Did you receive the COVID vaccine? Any boosters?Additional CommentsSUBMIT HERE
