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Monarch Herbs & Apothecary Herbal Remedies

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Herbal
Questionnaire

Please fill out the following form to help us understand your physical condition.

First Name

Last Name

Email Address

Date of Birth

Phone

Address

Primary Complaint

Secondary Complaint

Any other health concerns?

Are you currently having any of the following symptoms?

High Blood Pressure

Low Blood Pressure

Heart Problems

Asthma

Shortness of breath

Allergies

Gas/Bloating

Heartburn/GERD

Undigested food in stools

Consitpation

Diarrhea

Loose Stool

Skin Rashes or skin irregularities

Excessive or lack of sweating

Enlarged lymph nodes

Enlarged liver

Hepititis

Kidney Stones

Frequent Urination

PMS

Cancer

Sinus Problems

Frequent colds/flu

Cold hands or feet

Low Body Temperature

Eye Sight Difficulties

Hearing Difficulties

Memory Difficulties

Mood Swings

Depression

Anxiety

Thyroid Problems

Sleepiness After Meals

Trouble Sleeping

Diabetes - Type 1

Diabetes - Type 2

Anemia

Teeth Problems

Gallstones

Back Pain

Enlarged Spleen

Nerve Issues

Twitches / Spasms

Have you had any injuries? Any surgeries? How long ago?

Do you smoke?

Do you drink alcohol?

Do you do drugs?

Do you drink caffeine?

Do you eat a lot of sugar/sweets?

Do you take prescription drugs?

Do you take other herbal or vitamin supplements? What for?

For Women only

When was last menstrual cycle?

How long did it last?

Are you currently pregnant?

What symptoms do you have around your menses?

For Everyone

Tell me about your diet

Do you have food allergies or sensitivities?

After eating, do you have any of the following: bloating, heartburn, excessive thirst, constipation or tiredness?

Bowel movements: Do you have daily stools? How many? Consistency?

Urine output: Does your urine have a smell? Color?

Activity

Tell me about your sleep: How many hours do you sleep per night? Do you feel well rested when you awake?

Exercise: Do you exercise? What form of exercise? How long? How often?

Work: Is it standing? Sitting? Strenous? How many hours per day do you work?

Extra Curricular Activities: What else do you do that you enjoy? Or not enjoy?

Emotional

Rate your stress: 1-low to 5-high

Are you content with life in general? Why or why not?

Are there any predominant emotions that you feel?

Energy

Do you feel like you have enough energy to make it through the day?

How high is your sex drive? 1-low, 5-high

Do you prefer a warm climate or cold climate? Do you prefer to be warm or cold?

Additional Documents to Review:

If you have additional documents you wish for me to review, upload them here:

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I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Monarch Herbs - Herbal Products for Health & Wellness

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Herbal Questionnaire

For Women only

For Everyone

Activity

Emotional

Energy

Additional Documents to Review:

If you have additional documents you wish for me to review, upload them here:

Monarch Herbs - Herbal Products for Health & Wellness

Herbal
Questionnaire