Case Studies: Student must as instructed by course materials. Fill out form below for 5 different people (imaginary is okay). Master Herbalist Questionnaire Date: _____________________ Name: _________________________________ Age: ______ Birth date:_____________ Address: ________________________________________________________________ Home Phone: _________________________ Work Phone:________________________ Height: _________ Weight: _________ 1 year ago:__________ 5 years ago:_________ Occupation: _______________________________________? Full Time ?Part Time Living situation: ?Alone ?Friends ? Partner ? Spouse ? Parents ?Children ?Pets 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: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Please list any current health conditions diagnosed by a medical doctor: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Please use this form as a source of reference when conducting your Case-Studies. Treat this part as information only as you are not to treat or prescribe treatment for any specific diseases It is important to know if the client is receiving treatment from other practitioners and what these entail Since legally you are not allowed to diagnose disease, it is helpful to get one from an MD When was your last physical exam? ________________________________________________________________________ Please list all herbs, vitamins, and dietary supplements you are currently taking, includingdosage and frequency: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ List all medications you are currently taking (including aspirin, antacids, etc.) indicatingwhether they are over the counter (OTC) or Prescription, including dosage and frequency: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ List all medications, herbs, foods, environmental factors, to which you have a knownallergy: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ This is important information to have in order to avoid any interactions. Please use your textbook as well as the A-Z Guide to Drug-Herb-Vitamin Interactions for reference This is important information to have in order to avoid any interactions. Please use your textbook as well as the A-Z Guide to Drug-Herb-Vitamin Interactions for reference You have to keep these in mind when making suggestions. For example, someone allergic to ragweed may have a reaction to Chamomile DIETARY INFORMATION Describe below your typical meals. Please be as specific as possible. For example, instead of oil note 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 orange juice, one cup of coffee, etc.,). Breakfast: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Morning snack(s): ________________________________________________________________________ ________________________________________________________________________ Lunch: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Afternoon snack(s): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Refer to the Nutritional Guidelines booklet. Keep in mind food combining and healthy substitutions you can suggest. (E.g. soy or rice milk instead of cows milk) Refer to the Nutritional Guidelines booklet. Keep in mind food combining and healthy substitutions you can suggest. (E.g. whole-grain bread instead of white) Dinner: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Daily filtered or spring water consumption (number of glasses/day): ________________ Any recurring food cravings (such as salt, starch, sugar, chocolate, etc.) please list asmany as applicable including time of day or month: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ FAMILY HISTORY Please describe any relevant or major health related issues: (cancer, mental illness,diabetes, heart disease, etc.) Mother: _________________________________________________________________ Father: __________________________________________________________________ Sister(s): ________________________________________________________________ Brother(s):_______________________________________________________________ Maternal Grandmother: ____________________________________________________ Maternal Grandfather: _____________________________________________________ Paternal Grandmother: _____________________________________________________ Paternal Grandfather: ______________________________________________________ Refer to the Nutritional Guidelines booklet. Keep in mind food combining and healthy substitutions you can suggest. (E.g. extra virgin olive oil instead of corn oil) Explain the dangers of tap water and the importance of 8-10 glass per day of pure water May indicate the presence of Candida, parasites, food allergies or sensitivites, as well as vitamin, mineral, and EFA deficiencies This will shine a light on susceptibility to certain diseases and you may want to offer preventative measures. (E.g. regular exercise to prevent diabetes) MEDICAL HISTORY List all major health problems including any operations: PROBLEM YEAR ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ GENERAL HEALTH Cardiovascular Skin Muscles/Joints ? gh blood pressure ? Boils ? Backache ? Low blood pressure ? Bruises ? Broken bones ? Pain in heart ? Dryness ? Limited mobility ? Poor circulation ? Itching ? Arthritis ? Swelling ? Varicose veins ? Bursitis ? Stroke/murmur ? Skin eruptions ? Weakness Respiratory Urinary/Kidney Gastro-Intestinal ? Chest pain ? Excessive urination ? Belching ? Difficulty breathing ? Water retention ? Colitis ? Cough ? Burning urine ? Constipation ? Tuberculosis ? Kidney stones ? Abdominal pain ? Congestion ? Lower back pain ? Liver disorders ? Itchy ears/eyes ? Wheezing ? Gallstones ? Asthma ? Circles under eyes ? Ulcers ? Coughing up blood ? Blood in urine ? Digestive troubles This will help you in designing a nutrition, herb, and exercise program. Please note the limitations these might present (E.g. detoxification may be too drastic for someone suffering from a serious health condition.) These will give you any indication as to which areas may need some extra support. Keep these in mind when suggesting herbal remedies (e.g. people with high blood pressure should not take licorice.) Eyes, Ears, Nose and Throat ? Ear aches ? Eye pains ? Failing vision ? Hay fever ? Sinus infections ? Sinus congestion ? Sore throat ? Tonsils ? Hearing loss ? Canker sores ? Nosebleeds ? Difficulty breathing General ? Fatigue ? Night sweats ? Fever ? Excessive thirst ? Loss of appetite ? Always hungry ? Difficulty sleeping ? Irritability ? Cold hands and feet Male Reproductive ? Burning/discharge ? Lumps/swelling of testicles ? Painful testicles ? Vasectomy Female Reproductive Age of first period: ___ ? Irregular cycles ? Pre-menopausal ? Heavy bleeding ? Blood clots ? Menopause ? Vaginal discharge ? Vaginal itching ? Pains/cramps ? Painful intercourse ? Vaginal dryness ? Pelvic pain ? Breast pain ? Breast lumps ? Anemia ? Infertility ? Genital herpes ? Hot flashes ? Mood Swings ? PMS ? Not able to conceive Contraceptive/Pregnancy story ? Oral contraceptives ? Rhythm-method ? I.U.D. ? Diaphragm ? Condoms ? Mucous-method ? Cervical Cap ? Spermicides ? Fertility lens Please list each pregnancy you have had, including miscarriages: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ These will give you any indication as to which areas may need some extra support. Keep these in mind when suggesting herbal remedies (e.g. someone taking oral contraceptives will require additional nutrients, such as vitamin B6.) CURRENT STATE OF EMOTIONS AND SPIRITUAL WELL-BEING Please click all those that describe you: ? I am often not able to express my emotions. ? I am dissatisfied with my job. ? I am often stressed out and not able to cope properly. ? Even though Im in a relationship, I often feel lonely. ? I often feel anxious and nervous for no good reason. ? I dont sleep well at night and have a hard time waking up in the morning. ? I often suffer from bad dreams and nightmares. ? There are many things Id like to change in my life I just dont have the means. ? I have very low energy and often feel exhausted mentally and physically. ? I dont enjoy my work and would rather be doing something else. ? I find my children irritating and hard to relate to. ? I have very few hobbies. ? I often feel depressed for no reason. ? I often become angry with people and feel guilty about it later. ? I have a hard time letting go of the past. ? I dont look towards the future with much enthusiasm. ? I am not able to concentrate for extended periods of time. ? My outlook is more negative than positive. ? I spend a great deal of time worrying about what people think about me. ? I tend to see the good in people. ? I have a great sense of humor and love a good joke. ? I receive great joy from my family. ? My outlook on life is positive. ? My job uses all my greatest talent. ? I have plenty of energy to do all the things I want. ? I sleep well at night and feel rested in the morning. ? I can concentrate on the task at hand for as long as it takes. ? I have a strong spiritual faith. ? I am able to express anger constructively. ? I practice meditation or other relaxation techniques. ? I try to maintain peace of mind and tranquility. ? I have many close friends that I can always count on. ? I accept full responsibility for my actions. ? I trust my intuition and believe that things happen for a reason. ? I do not harbor any resentment from the past. ? I can feel completely fulfilled even if Im alone. ? I have many hobbies and interests to keep me preoccupied. ? How I see myself is more important than how others see me. ? I often go out of my way to help others. If you see more clicks in the top part than at the bottom youll know that you are dealing with a more negative person and the treatment will entail extra effort on your part, including nurturing the soul, boosting self-confidence, releasing stress, learning relaxation, etc. Please list approximate dates and describe the nature of any traumatic experiences youhave had in the past 7 years (divorce, surgery, end of a relationship, loss of job, change of residence, injury, death of a loved one, etc.) YEAR EVENT ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ LIFESTYLE HABITS Do you engage in regular physical activity? ? Yes ? No If yes, for how many minutes? _____________How often? __________________ Do you smoke tobacco? ? Yes ? No If yes, how much? ________/day Do you drink alcohol? ? Yes ? No If yes, how much? ________________ How often? __________________ Do you drink coffee and/or caffeinated beverages? ? Yes ? No If yes, how much? ________________ How often? __________________ How many hours of television do you watch in a week? ______________ Do you use artificial sweeteners? ? Yes ? No Please use this space to add any other information about yourself that you think will be helpful: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Such events can greatly influence a persons health and state of mind. Many diseases are brought on by emotional trauma and can best be treated by healing the underlying issues. Often just talking about these things can be helpful. Be a good listener and offer coping tools and support groups. 3-5 times per week for at least 30 minutes is recommended Obviously consumption of these should be reduced or eliminated TV can affect health and state of mind Offer alternatives, discuss dangers (stevia, honey) Herbalists Comments and Suggestions Dietary Suggestions: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Recommended Herbs and Nutrients including dosage: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Use the Nutritional Guidelines booklet to offer general recommendations and substitutions based on the persons diet. Emphasize the importance of optimum nutrition in relation to health. Discuss the importance of drinking adequate filtered or spring water. Talk about microwaves, artificial sweeteners, GE foods and other dangers the person may not be aware of. Emphasize the importance of eating organic foods as much as possible. Use the Materia Medica booklet and the One Earth Herbal Sourcebook for reference. Keep in mind other nutrients or drugs the person may be taking and refer to the A-Z Guide to Drug-Herb-Vitamin Interactions in order to avoid harmful combinations. Dont forget about: dosage, taken with food or without, length of treatment, things to avoid, etc. (A detoxification program is usually a good way to start off most people) Lifestyle modification changes: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Relaxation techniques and exercise: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Other suggestions: ________________________________________________________________________ ________________________________________________________________________ This could include: tools to help quit smoking, eliminating exposure to chemicals (e.g. using natural cleaning products), cooking more meals at home instead of eating out, using natural skin care products, getting more fresh air, avoiding alcohol (except for the occasional glass of red wine), and any other things that would pertain to the persons lifestyle habits. Suggest tapes or classes for relaxation, Yoga, meditation. Emphasize the importance of exercise. Design a program to suit the persons physical condition and lifestyle. Offer tools to reduce stress. Offer suggested reading materials. This could include a referral to a massage therapist, reflexologist, chiropractor, etc. (Its a good idea to set up a network with other natural health professionals). After filling out the questionnaire youll need to spend a great deal of time talking to the person and going through each point to enable you to offer very personal recommendations that could benefit his/her well-being, in addition to the general recommendations that everyone could benefit from.
