Michele’s Garden
Translating Ancient Natural Health Traditions and Old World Culinary Customs to bring about Health and
Balance
349 S. Ridgecrest Avenue
Rutherfordton, NC 28139
828-287-4959
michelesgardn@yahoo.com
HOLISTIC CHEF HERBALIST INSTRUCTOR
Herbal and Nutritional Consulting
Client Instructions and Correspondence
HEALTH INVENTORY
Date _______________________
Name ___________________________________________Age _______ Birth date __________
Address _______________________________________________________________________
______________________________________________________________________________
Home Phone _______________ Work Phone _______________ Cell Phone _______________
Height ___________ Weight ___________ 1 year ago ___________ 5 years ago ___________
Occupation: _______________________________________ Full time _____ or Part time _____
Living situation: Alone Friends Partner Spouse Parents Children Pets
Names and ages of those living with you: _____________________________________________
______________________________________________________________________________
What are your major health concerns and intentions for your visit today?
______________________________________________________________________________
______________________________________________________________________________
Please list any other health care providers or consultants you are currently working with:
______________________________________________________________________________
______________________________________________________________________________
Would you like any of them to receive a copy of your recommendations?
Please list all herbs, vitamins, and dietary supplements you currently take, citing brand name whenever possible
(use additional space on back if needed):
PRODUCT DOSAGE FREQUENCY (NUMBER/DAY)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
List all medications you are currently taking (including aspirin, antacids, etc.) indicating whether they are over
the counter (OTC) or Prescribed (P). Use additional space on back if needed.
PRODUCT OTC or P? DOSAGE FREQUENCY (NUMBER/DAY)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
List all medications, herbs, etc., to which you have a known allergy:
______________________________________________________________________________
______________________________________________________________________________
DIETARY INFORMATION
Describe below your typical meals. Be specific. For example, instead of “oil,” list type of oil, such as olive, corn,
etc. Instead of “bread,” list whether white or whole grain, etc. Instead of “vegetables,” list the type of vegetable,
how prepared, canned, frozen, or fresh, etc. Please include all beverages, type and quantity (two cups of
coffee, one glass of orange juice, etc.):
Breakfast: ______________________________________________________________________
______________________________________________________________________________
Morning snack(s): _______________________________________________________________
Lunch: ________________________________________________________________________
______________________________________________________________________________
Afternoon snack(s): ______________________________________________________________
Dinner: ________________________________________________________________________
______________________________________________________________________________
Daily water consumption (number of glasses per day): ___________________________________
Any recurring food cravings (such as salt, starch, sugar, chocolate, etc.):
______________________________________________________________________________
Please list any known food allergies/sensitivities:
FOOD DESCRIBE REACTION
______________________________________________________________________________
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Typical times of meals and snacks:
______________________________________________________________________________
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FAMILY HISTORY
Describe any relevant or major health related issues (alcoholism, high blood pressure, cancer, diabetes, heart
disease, psychiatric illness, osteoporosis, other addictions, other illnesses):
Mother: ________________________________________________________________________
Father: _______________________________________________________________________
Sister(s): ______________________________________________________________________
Brother(s): _____________________________________________________________________
Maternal Grandmother: ___________________________________________________________
Maternal Grandfather: ___________________________________________________________
Paternal Grandmother: ___________________________________________________________
Paternal Grandfather: ___________________________________________________________
Other family members with pertinent issues, or recurring family health trends:
______________________________________________________________________________
PAST HEALTH PROBLEMS
List all major health problems including any operations:
PROBLEM YEAR
______________________________________________________________________________
______________________________________________________________________________
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GENERAL
Mark all that apply. If mild, mark “1”; if strong, mark “2”.
____Awakens, can’t go back to sleep ____Increase in weight (recent)
____Bad dreams ____Lack of sensation somewhere
____Blurred vision ____Likes depressants
____Brown spots, bronzing of skin ____Likes stimulants
____Bruises easily ____Lower back pain
____Can’t gain weight ____Muscle cramps
____Can’t lose weight ____Nails split, brittle
____Can’t get started without coffee ____Nose bleeds frequently
____Chemical or spray poisoning ____Pollution heavy in environment
____Chronic fatigue, depression ____Ringing in ears
____Cries easily without apparent cause ____Pulse speeds up after meals
____Depressed for long periods ____Sensitive to cold weather
____Earaches ____Sensitive to hot weather
____Eat often or else faint/nervous ____Sensitive to high humidity
____Eyes often red/inflamed ____Sensitive to low humidity
____Face, eyes get puffy ____Sexual desire decreased
____Facial twitches ____Sexual desire increased
____Gum problems ____Stuffy nose during the day
____Headaches ____Stuffy nose in evening/night
____Headaches in morning, wearing off ____Tendency to anemia
____Heart palpitations when hungry ____Tremors in hands or neck
____Heart palpitation after eating ____Varicose veins
____Highly emotional ____Highly controlled
____Weight gain in upper arms, shoulders, back of neck ____Impaired hearing
CARDIOVASCULAR
____High blood pressure ____Low blood pressure
____Pain in heart ____Poor circulation
____Swelling ____Stroke/murmur
____Fast, light pulse ____Slow, strong pulse
____Cold bodied ____Warm bodied
____Sometimes dizzy or faint ____Frequent physical activity
____Hands cold, clammy or dry ____Hands warm, sweaty
____Hypertension, not responding to diuretics ____Hypertension responds to diuretics
____Palpitations either as an adolescent or before menses
SKIN
____Boils ____Bruises ____Varicose veins
____Dryness ____Itching ____Skin on trunk is dry
____Oily scalp or hair ____Dry scalp or hair
____Skin eruptions are deep, not coming to a head
____Skin eruptions are superficial, come to a head
____Cracks, fissures on heel, elbow, feet, heal poorly
MUSCLES/JOINTS
____Backache ____Broken bones ____Mobility
____Arthritis ____Bursitis ____Weakness
UPPER GI
____Sometimes nausea in evenings ____Sometimes nausea in mornings
____Mouth frequently too dry ____Sometimes excess salivation
____Duodenal ulcer ____Stomach ulcer
____Sometimes foul burps ____Strong, demanding hunger
____Butterflies in stomach ____Seldom eat breakfast
____Often don’t finish meals ____Often eat to calm down
____Receding gums ____Frequent use of alcohol
____Frequent poor appetite ____Bitter taste in morning
____ “Dragon breath” in morning ____Acid indigestion at night
____Frequent mouth cold sores ____Sometimes difficulty in swallowing
____Indigestion after eating
LOWER GI
____Constipation with gas ____Stools loose with gas
____Frequent constipation ____Digestion unusually rapid
____Light colored, hard stools ____Loose stools when tired/stressed
____Intestines often bloated ____Dark, soft stools
____Constipation with hemorrhoids ____Quick defecation after eating
____Constipation with painful defecation ____Constipation w/fully formed stools
____Constipation w/hard, marbly stools ____Tongue often coated
LIVER
____Dry, even scaly skin ____Moist, sometimes oily skin
____Hay fever or asthma ____Hives from food or drugs
____Craves fruit or sweet ____Craves proteins, fats
____Frequent trouble digesting fats ____Fever with sweat when sick
____Acne on face AND buttocks ____Seem to have low blood sugar
____Had hepatitis in past ____Frequent use of alcohol
____Work with solvents ____Psoriasis, eczema, dermatitis
____Frequent minor illnesses ____Don’t sweat when sick
RENAL
____Standing too quickly causes faintness/dizziness
____Standing too quickly makes pulse roar in ears ____Frequent water retention
____Frequent flushing or blushing ____Urine usually dark
____Moderate low blood pressure ____Moderate high blood pressure
____Frequent thirst ____Craving for salt
____Urine always light colored ____Wakes up at night to urinate
LOWER URINARY TRACT
____Frequent urination, small amounts ____Infrequent urination, copious
____Sometimes dribble afterwards ____Frequent bladder infections
____Demanding need to urinate ____Mucus in urine
____Benign prostatic hypertrophy ____Dull ache after urination
REPRODUCTIVE
MEN
____Frequent cannabis user ____Pain or ache after orgasm
____Difficult maintaining erection when in the mood ____Benign prostatic hypertrophy
WOMEN
____Cycle more than 28 days ____Cycle less than 28 days
____Miss some periods ____Water retention before menses
____Menses slow starting with cramps ____Menstruation always lengthy
____Constipation before, loose stools after menses starts
____Frequent Class II Pap smear ____Always hungry before menses
____History of PID, cervicitis ____Breasts tender before menses
____Miscarriages, problem pregnancy ____Palpitations before menses
____Period late with altitude change ____Period early with altitude change
____Tried, but couldn’t take birth control pills ____Hot flushes
Contraceptive/Pregnancy History
____BC Pills ____Rhythm ____IUD
____Diaphragm ____Condoms ____Mucous method
____Cervical Cap ____Spermicides ____Fertility lens
Please list each pregnancy you have had, including miscarriages and abortions:
_________________________________________________________________________
_________________________________________________________________________
RESPIRATORY
____Shortness of breath when standing or walking ____Slow, strong pulse
____Tobacco smoker ____Sometimes hyperventilates
____Difficulty swallowing mucus ____Rapid, shallow breather
____Yawns frequently ____Frequent chest colds
____Sometimes wakes up choking or gasping for breath
MUCUS
____Sores, cracks, fissures in mouth, anus, vagina ____Lips often dry, chapped
____Food often causes intestinal distress as it passes ____Gets sore throat easily
LYMPHATIC
____Recuperates slowly if ill ____Recuperates quickly if ill
____Injuries heal slowly ____Injuries heal quickly
____Eczema, dermatitis ____Asthma or hay fever
____Arthritis or rheumatism
CURRENT STATE OF EMOTIONS AND SPIRITUAL WELL-BEING
Take time to think about and answer the following questions:
Are you completely satisfied with your living conditions?
Are you able to express your feelings and emotions?
Is there an excess of stress in your life? What is causing the stress?
Are you satisfied with your job?
If in a relationship, are you satisfied with it? Are you lonely?
Is there something you would like to change in your life? Can you change it?
Are you a “nervous type” of person? What sorts of things make you nervous?
Do you sleep well? How many hours (in a 24-hour period)?
Do you dream? Do you remember your dreams?
Are you satisfied with your energy level? Do you often feel exhausted?
Is it easy to wake up in the morning? Do you enjoy your work?
Do you have hobbies/activities you enjoy outside of work?
Which of these feelings dominate your life?
Joy Happiness Anger Sadness Fear Sympathy Worry Depression
Other
Do you believe in a higher power? Are you at peace with this belief/relationship?
Please list approximate dates and describe the nature of any traumatic
experiences you have had in the past 7 years (divorce, loss of lover, loss of job,
change of residence, injury, death of a loved one, etc.)
YEAR EVENT
__________________________________________________________________________
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LIFESTYLE HABITS
Routine physical exercise: Type of exercise ______________________________________
For how many minutes? ___________ How often? _______________________
Tobacco use: How much? _______________ Previously? _______________________
Alcohol use: How much? _________________ How often? _______________________
Caffeine use: How much? _________________ How often? _______________________
Mood altering substances (such as cocaine, marijuana, etc.):
_________________________________________________________________________
How many hours of television do you watch in a week? _____________________________
Please use this space to add any other information about yourself that you think will be helpful:
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THIS FORM IS FOR USE BY MICHELE TANNER, OUR PROFESSIONAL CLINICAL
HERBALIST. MICHELE WOULD PREFER TO HAVE THIS PRIOR TO YOUR FIRST
CONSULTATION SO SHE CAN PREPARE MORE THOROUGHLY. YOU MAY SAVE THIS TO
YOUR COMPUTER, FILL IT IN, AND E-MAIL IT TO HER AT MICHELESGARDN@YAHOO.COM
OR MAIL IT TO HER AT 349 S. RIDGECREST ST., RUTHERFORDTON NC 28139.
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