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Physicians Herbal Formula
THE QUESTIONNAIRE FOR CUSTOM MADE HERBAL FORMULA
Name:
First
Last
Basic Demographic:
Age:
Sex:
Male
Female
Type of Residence:
Type of work:
Any particulars worth mentioning:
HISTORY OF PRESENT SYMPTOM:
What is the Chief Symptom?
How long has been the duration of it?
When is the symptom?
In the morning
in the afternoon
in the evening
Any particular environment or season?
How long does the symptom last and how often is it?
How severe is the symptom? Please Grade it (from 1 to 10):
What factors make the symptom worse?
What factors alleviate the symptom?
Are there any associated symptoms or physical signs?
Have you been evaluated for the chief symptom by a medical doctor?
Yes
No
What were the diagnosis and what treatments or medications were prescribed? What has been the response to treatment?
PAST MEDICAL HISTORY (please check any that apply):
Checkbox
Hypertension
Diabetes mellitus
High Cholesterol
Head and Neck Disease
Heart Disease
Lung Disease
Gastrointestinal/Liver Disease
Genitourinary Disease
Musculoskeletal Disease
Neuropsychiatric Disease
Endocrine Disease
Current Medications?
Any Surgeries?
Any Allergies?
SOCIAL HISTORY:
Smoking?
Yes
No
Drinking?
Yes
No
Recreational Drugs?
Yes
No
REVIEW OF SYMPTOMS:
Please list all other major symptoms whether or not they seem related to the chief symptom:
ANY PHYSICAL SIGNS YOU HAVE OR YOUR MEDICAL DOCTOR HAS INFORMED YOU:
ANY SIGNIFICANT LAB OR RADIOLOGICAL ABNORMALITIES:
YOU CAN E MAIL THE PICTURES OF YOUR FACE AND TONGUE, IF YOU WISH.
