1) PRINT and fill out forms below. Bring them to your appointment.
2) For phone appointments: MAIL with payment and full body photo, before scheduled appointment, to:

Pat O’Brien
P.O. Box 264 Andover, NY 14806


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 $95 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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