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Terra Ken
Herbal Remedies

 

Consultation Profile / Custom Blending

Name:

Street Address:

City:                                                  State:                  Zip code:

Phone:                                               Best time to call:

Male or Female:                                  Age:

 

Please print and fill in all of the information requested as completely and accurately as possible. The more information you can give me, the better equipped I am to target your individual needs. All of the information that you provide will be kept confidential and used for Terra Ken purposes only.

 

PART ONE—Lifestyle Analysis

Habits:

 

Dietary preferences/ restrictions:

Sample of day’s menu

Breakfast:

Lunch:

Dinner:

 

Tobacco use

How much?

Previously?

How much?

How long?

Yes / No

        

Alcohol use

        

Yes / No

        

How much caffeine do you use each day?

 

 

Mood altering substance use (i.e. marijuana, cocaine- past and present):

 

 

 

Check all the white boxes across a row if a statement applies to you.  For example, if you experience lack of energy, you would check boxes 1, 3, 4, 5, and 7 across the first row.  After you’ve completed all the questions, add up the total number of checks in each vertical column, 1-9. Enter the column totals in the empty spaces at the bottom of the page.

SYSTEMS

1

2

3

4

5

6

7

8

9

Lack of energy

 

  

 

 

 

  

 

    

Frequent illness

        

 

        

Body odor and/or bad breath

 

 

      

 

      

Difficulty in digesting certain foods

 

      

 

        

Frequent consumption of red meat

  

 

 

    

 

      

Monthly female concerns

  

 

        

 

 

  

Frequent use of antibiotics

  

 

    

 

        

Heavy alcohol consumption

      

 

    

 

    

Frequent mood swings

      

 

    

 

    

Food allergies

 

      

 

 

      

Bags under eyes

    

 

 

      

 

  

Smoking

    

 

 

  

 

      

Poor concentration or memory

    

 

 

    

 

    

Poor resistance to disease

 

      

 

        

Belching or burping or gas after meals

 

      

 

        

Stressful lifestyle

    

 

 

 

  

 

    

Skin/complexion problems

 

 

        

 

 

 

Cravings for sweets or processed foods

      

 

    

 

    

Regular consumption of dairy products

  

 

      

 

      

Feeling low, uninterested, or depressed

  

 

  

 

          

Too little sleep or restless sleep

      

 

    

 

    

Menopausal concerns

      

 

    

 

  

 

Frequent urinary concerns

              

 

  

Hair loss

    

 

 

    

 

  

 

Sore or painful joints

    

 

  

 

      

 

Difficulty in maintaining ideal weight

      

 

 

  

 

  

 

Low endurance during activity

    

 

    

 

    

 

Poor eating habits

 

 

        

 

    

Slow recovery from illness

  

 

 

      

 

    

Irregular or infrequent bowel activity

 

 

  

 

          

Lack of appetite

 

    

 

    

 

    

Low sex drive

            

 

    

Brittle or easily broken fingernails

 

              

 

Dry, damaged, or dull hair

 

            

 

  

High-fat diet

 

 

 

            

Unsettled, apprehensive, pressured

      

 

    

 

    

Low-fiber diet

  

 

 

            

Muscle cramps

      

 

        

 

Exposure to air pollution

        

 

 

      

Heavy caffeine consumption

      

 

    

 

  

 

Feeling out of control

      

 

 

      

 

Food/chemical sensitivities

 

 

    

 

        

Problems with yeast/fungus

 

 

    

 

        

Structural weakness

 

            

 

 

Excessive worry

 

    

 

          

Easily irritated/angered

  

 

  

 

    

 

    

Too little exercise

  

 

  

 

    

 

  

 

Excessive mucus

  

 

      

 

      

Total

                  

 

Stresses:
Please explain the stresses in your life (family, work, self, etc.)

 

 

Do you suffer from depression?  Please explain:

 

 

Are you frequently angry?  Please explain:

 

 

Do you often feel anxious or nervous?  Please explain:

 

 

Are you currently overweight?

If yes, how many pounds do you need to lose?

Do you exercise?

What types?

 

How often?

What types of activities do you use to relax or have fun?

 

How often do you enjoy these activities?

 

What health problems do you have that you would most like to change (if any):

 

 

PART TWO –Health History

Is your general health excellent, good, fair, or poor?

 

Are you currently using any medications (prescription or over the counter)?

If yes, please list:

 

 

Are you currently using any vitamins, herbs, or other nutritional supplements?
If yes, please list (include brand names, if possible):

 

 

Do you have any allergies to drugs, plants, pollens, foods, etc.?  If yes, please list:

 

 

Please list any hospitalizations/ operations (include pregnancies, miscarriages, and abortions):

 

 

Please list any current medical conditions (high blood pressure, diabetes, thyroid imbalance, asthma, etc.):

 

 

Please list any past medical conditions (include dates):

 

 

Please indicate if any blood relative has/had any of the following diseases; Alcoholism, High Blood Pressure, Cancer, Diabetes, Heart Disease, Osteoporosis, other addictions, other serious illnesses:

 

 

 

Women only:

Are you trying to get pregnant?

How long?

Current birth control method:

How long?

Problems with it?

 

Past birth control methods:

 

Normally (not on pills), the number of days from the start of one period to the start of the next:

Number of days of flow:

Amount of bleeding:

Amount of cramps:

Premenstrual symptoms:

Starting when?

Any current changes in your normal pattern?

 

Any bleeding between periods?

When?

Any unusual pelvic pain, pressure, or fullness?

When?

Describe:

 

 

Any unusual vaginal discharge or itching?

Describe:

 

 

How long?

Past treatment:

 

Any sexual concerns?

 

 

 

PART THREE- Sensory Preferences

Please circle any of the following SCENTS that you prefer:

Anise

Frankincense

Orange

Basil

Geranium

Palma Rosa

Bergamot

Ginger

Patchouli

Black Pepper

Grapefruit

Peppermint

Camphor

Jasmine

Pine

Cardamom

Juniper

Rose

Carrot seed

Lavender

Rosemary

Cinnamon (Cassia)

Lemon

Rosewood

Red Cedar wood

Lemongrass

Sage

Roman Chamomile

Lime

Sandalwood

Clary Sage

Marjoram

Spearmint

Clove

Melissa (Lemon Balm)

Tea tree

Cypress

Myrrh

Thyme

Eucalyptus

Neroli

Vanilla

Fennel

Nutmeg

Ylang Ylang

Please list any flavors or spices that you DO NOT like in beverages (i.e. licorice, cinnamon, mint, vanilla, etc.):

Please use this space to add any other information about yourself that you think will be of help to me:

 

 

 

 

 

Thank you for your information, if you have any questions please call 706-783-2225

Mail this form to:
Terra Ken Herbal Remedies Shoppe
P.O. Box 4
Comer, GA 30629