APPOINTMENT QUESTIONNAIRE AND RELEASE
FORM
Appointment Release
I understand that the appointment/advice provided uses alternative methods and opinions.
If I have a serious problem, health emergency or life threatening condition, I will
consult a Western physician or the nearest ER. It is strictly my decision to investigate
and use Ayurvedic/Chinese medicine alternatives. Pat O'Brien does in no way suggest
stopping any prescriptions, treatments or medical advice given to me by my medical doctor.
I agree to withhold Pat O’Brien from any liability arising from any treatments or
advice given to me through this website/at this office at any given time. Furthermore, I
understand that there is no guarantee of a cure for my medical condition using Ayurvedic
and Chinese natural alternatives. I also understand that herbs can have side effects and
should a problem occur, I will discontinue their use immediately. If I decide to
take herbs beyond the length of time recommened for me, I do so only at my own risk.
Therefore, I release and discharge Pat O’Brien of all claims and demands which I now
have or may have in the future in relationship to the services I have requested. Last, I
agree to pay a fee of $75 for missed appointments without first having called in, or
notified by mail, to cancel the appointment within 24 hours of the scheduled appointment.
Signed _____________________________
Date _________________
Name ___________________________________________________________
Address __________________________________________________________
_________________________________________________________________
Phone _____________________ Date of birth _____________
Age _____
Work # ____________________ Cell # __________________
Referred by _____________________ E-mail _____________________________
PSYCHOLOGICAL
*Have you had any psychological counseling? When? For what reasons?
_____________________________________________________________________
_____________________________________________________________________
*If you could, would you change anything about your current life?
_____________________________________________________________________
*happy/optimist? __________ unhappy/pessimist/realist? _________
*What is your current method of dealing with stress?
_____________________________________________________________________
*Answer yes to the category which best describes your moods when having a bad day/week:
| ________ (K/BL/S) Threatened, fearful, paranoid, shy, sexual anxiety, protective of self |
| ________ |
| ________ (H/SI) Easily excited, excessive laughter, hyperactive, impulsive, boisterous |
| ________ |
| ________ (Lu/LI) Sad, depressed, lethargic, low self-esteem, self-pitying |
| ________ |
| ________ (P/ST/SP) Worried, skeptical, suspicious, distrusting, overly dependent |
| ________ need constant reassurance, confused, indecisive, overly analytical |
| ________ (LV/GB) Tense, angry, short tempered, stubborn, irritated, frustrated, controlling, rigid |
| ________ critical, domineering, jealous |
PHYSICAL STATUS
*your height: ___________________
*current weight: ____________________
CURRENT MEDICATIONS/DRUGS
*List current use of drugs, prescriptions, alcohol, antibiotics (what, dosage, how often)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
*List vitamins, herbs, natural food supplements (what, how often used, and amounts
[ex: 500 mg vitamin C]):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
ACCIDENTS
*Describe any accidents you have had, when they happened, and what damage occurred:
_______________________________________________________________________
SURGERIES:
*List any surgery you have had, when it occurred, and for what reason:
_______________________________________________________________________
_______________________________________________________________________
MEDICAL PROBLEMS
*List current health problems, be very specific
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
*List past medical problems, illnesses
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
DIETARY HABITS
*List your typical breakfast, lunch, and dinner (be very specific) :
Breakfast _______________________________________________________
Lunch ________________________________________________________
Dinner _______________________________________________________
*Favorite junk food or binge food ___________________________________________
*Other foods you tend to eat a lot of _______________________________________
*Number and kinds of beverages consumed per day __________________________
*Do you drink coffee? ______ How much? ___________ * alcohol? ______ amt: _________
*Do you eat spicy food? ______ garlic? _____ black pepper? ______ salt intolerant? ______
*check if you eat any of the following regularly or during the month:
| apples ____ | mangoes____ | tangerines ____ lemons ____ |
| pears ____ | peaches ____ | grapefruit ____ |
| dates ____ | bananas_____ | rhubarb ____ |
| grapes ____ | pineapple____ | cranberry juice ____ |
| plums ____ | oranges ____ | kiwis ____ |
| melons ____ | apricots ____ | strawberries ____ |
* Check if you have any of the following physical symptoms:
| ____ Chronic headaches | ____ Chronic fatigue _____ Cartilage damage |
| ____ Bleeding gums ____ Receeding gums |
____ Tremors _____ Stiffness in joints |
| ____ Loose Bowels/Diarrhea Tendency | ____ Palpitations _____ Abdominal bloating |
| ____ Frequent infections | ____ Cracking in the joints _____ Blood in stools |
| ____ Red skin rashes | ____ Muscle weakness _____ High blood pressure |
| ____ Heartburn/Acid indigestion | ____ Dizziness/Lightheaded _____ High cholesterol |
| ____ Stomach ulcers/Canker Sores | ____ Ringing in ears _____ Eyes bloodshot |
| ____ Frequent sore throats | ____ Constipation |
| ____ Nausea/Poor Appetite | ____ Hair loss/Dry hair |
| ____ Clear/Colorless Urine | ____ Rough/dry/itchy/flaky skin |
| ____ Lethargy/Sleep long hours | ____ Insomnia/Restless sleep |
| ____ Diabetes | ____ See spots before eyes |
| ____ Dull aches and pains | ____ Dandruff /Itchy Scalp |
| ____ Fluid retention/Edema -swelling | ____ Muscle tension/cramps |
| ____ Cloudy urine | ____ Dry mouth/Dry nostrils |
| ____ Gas/Bloating after eating | ____ Sleep in stretched position |
| ____ Sleep in curled position | ____ Nose bleeds |
| ____ Night time urination | ____ Sharp throbbing or severe pains |
| ____ White pale face | ____ Red face |
| ____ Chills/feel cold often | ____ Always hungry/appetite out of control |
| ____ Frequent urination (over 5 x day) | ____ Dark urine |
| ____ Little/no thirst | _____ Thirsty a lot |
| ____ Cold hands and feet | _____ Hot flashes/Night sweats/or feel hot often |
| ____ Urine dribbling | _____ Painful urination/burning |
EXERCISE
*List type of exercise and amount per week/length of time practiced:
____________________________________________________________________
OCCUPATION
*List type and whether you are content with what you do
____________________________________________________________________
RELATIONSHIPS/FAMILY
*How is your relationship with your siblings, parents, spouse, children?
_____________________________________________________________________
*How is your social life? __________________________________________________
*Do you feel satisfied with your living arrangement? ______________________________
*FOR WOMEN ONLY:
Length of menstrual cycle between periods and number of days of actual period:
______________________________________________________________
Heavy blood flow or light? _________________________________________
Light for how many days? ________________________________
Menstrual cramps/clots?__________________________________
Painful breasts at onset of menstrual cycle? ____________________
Do you use/have you used any birth control pills or hormones? ______________________
Any bleeding between periods or discharge? ____________________________________
If so, what color? ________________________________________________________
Type of pms symptoms you experience: ________________________________
Vaginal dryness or pain during sex? ___________________________
*FOR MEN ONLY:
Infertility? ______________ Enlarged prostrate? ____________
Impotence? _____________ Prostrate infections? ____________
Premature ejaculation? ___________
Reduced sex drive? _____________
CONSTITUTION TENDENCIES
*check either V P or K (which describes you best)
CLIMATE WHICH BOTHERS YOU THE MOST
V – cold, windy, dry weather, the fall season
P – hot and humid weather, too much sun and heat
K – cold, wet, damp weather, especially winter and spring seasons
SLEEP
V - light sleeper, wakes easily, tends towards insomnia
P - moderate, 7 – 8 hours
K - heavy sleeper, difficulty in waking up, feel like daytime napping
WEIGHT
V – low weight, skinny or thin, hard to gain, veins and bones visible
P – medium weight, good muscles, gain and lose weight with some effort
K - always heavy, struggle to keep weight down
COMPLEXION
V - dull, brown, olive, darkish, tan easily
P – fair skin, with sometimes red flushed appearance
K - white, pale/pasty, sometimes puffy/bloated
SKIN TEXTURE AND TEMPERATURE
V - thin skin, dry, rough, cracked, cold, prominent veins
P - warm, moist, pink, freckles, acne, sunburn easily
K - thick skin, moist, cold, soft, smooth, white, oily skin and hair
HAIR
V - dry, scanty, thin, brittle, or falling out
P - moderate, fine, light brown or blonde, early grey
K - oily, thick, very wavy, abundant
CHEST SIZE
V - small, poorly developed
P - medium
K - large, broad or over developed
BODY SHAPE
V - very tall or short, or thin shaped, small/narrow shoulder width
P - medium width hips and shoulders and medium height
K - pear shaped, or broad shoulders/waist (for women: voluptuous)
ARMS
V - long, thin, spindly
P – medium, muscular
K - large, thick, round, flabby, soft or with fat
THIGHS
V - thin, narrow
P - medium
K - round, fat, or well developed, thick
APPETITE
V- variable, sometimes hungry, sometimes not
P - strong, voracious appetite, always hungry, love to snack
K - constant but low appetite
HABITS
V – hate routine, eccentric, imaginative, like art, plays, parks, traveling, variety
or risk
P - into sports, love outdoors, competition with others or self, goal achieving, or leader
K - like to luxuriate and relax, read a book, watch tv, have plenty of “quiet”
time
YOUR TONGUE
MY TONGUE COLOR IS red______ pink _______ pale _______
MY TONGUE HAS thick coating _____ no coating _______ thin coating ____
THE COLOR OF THE COATING IS white/greasy_______ yellow ________
MY TONGUE HAS A tremor_______scalloped edges/teeth imprints _______
YOUR FACE
HAS NORMAL COMPLEXION _______ PALE COMPLEXION ______
RED DISCOLORATION ________ SEVERE RED COLORING __________
YOUR ANKLES
HAVE SWELLING/WATER RETENTION ON THEM ______
NORMAL/NO WATER _________
YOUR TORSO, HANDS, ARMS, LEGS, CHEST, NECK
HAVE RED RASHES ON THEM ______
NO RED DISCOLORATIONS_______
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