Constitutional Intake Form Please click all that apply Name * First Name Last Name Email * Upper GI Sometimes nauseous in the mornings Sometimes nauseous in the evenings Mouth frequently too dry Duodenal ulcer Stomach ulcer Sometimes foul burps Butterflies in the stomach Seldom eats breakfast Often don't finish meals Often eat to calm down Receding gums Frequent use of alcohol Frequent poor appetite Strong, demanding hunger Bitter taste in the morning "Dragon breath" in the morning Acid indigestion at night Frequent mouth or cold sores Sometimes difficulty swallowing Indigestion after eating Lower GI Stools loose w/gas Constipation w/gas Frequent constipation Digestion unusually rapid Loose stools when tired/stressed Light colored/hard stools Dark soft stools Quick defecation after eating Intestines often bloated Constipation w/hemorrhoids " w/painful defecation " w/hard, marble like stools " w/fully formed stools " " alternate w/diarrhea Frequent need for laxatives Tongue often coated Mucus Don't sweat when sick Sores, cracks on mouth, anus, vagina Food often causes intestinal distress Get sore throat easily Lips often dry, cracked Liver / Renal Dry, even scaly skin Standing too quickly makes pulse roar in ear Moist, sometimes oily skin Standing too quickly causes faintness, dizziness Hives from food or drugs Wakes up at night to urinate Hay fever or asthma Frequent flushing or blushing Craves proteins or fats Water retention w/change of weather Craves fruits or sweets Moderate high blood pressure, craves fats Frequent trouble digesting fats Moderate low blood pressure, craves sweets Acne on face AND buttocks Frequent thirst Seems to have low blood sugar Craving for salt Had hepatitis in the past Urine always light colored Frequent use of alcohol Urine usually darker Work with solvents Psoriasis, eczema, dermatitis Lower Urinary Tract Frequent Minor illnesses Frequent urination Fever w/sweat when sick Infrequent urination, copious Don't sweat when sick Sometimes dribble urine afterwards Frequent bladder infections Lymphatic Demanding and sudden need to urinate Recuperates quickly if ill Mucus in urine Recuperates slowly if ill Benign prostatic hypertrophy Injuries heal quickly Dull ache after urinating Injuries heal slowly Eczema, dermatitis SKIN Asthma or hay fever Skin eruptions superficial, come to a head Arthritis or rheumatism Skin eruptions deep, not coming to a head Digest fats easily Oily scalp or hair Digest fats poorly Dry scalp or hair Cracks, fissures on heel, feet, slow healing Skin on trunk is dry Reproductive Sweat freely w/strong scent Pain or ache after orgasm Oily skin, facial acne Benign prostate hypertrophy Dry skin, cold hands and feet Difficult maintaining erection even if you feel in the mood Frequent cannabis user Fever w/sweat when sick Reproductive Cycle more than 28 days Shortness of breath when standing or walking Cycle less than 28 days Water retention before menses (hips, breasts) Water retention before menses (feet, hands) Usually craves fats & proteins before menses Usually craves sweets before menses Sides of breasts tender before menses Miss some periods Menses slow starting w/cramps Palpitations before menses Menstruation lengthy, frequent cramps Menstruation short, defined, few cramps Frequent Class II pap smears Miscarriages, problem pregnancy Menses late w/altitude change Tried, but couldn't handle birth control pills Sweat freely w/ strong scent Oily skin, facial acne Dry skin, cold hands and feet Frequent cannabis user Respiratory Shortness of breath when standing or walking Tobacco user Easy coughing up mucous Difficulty swallowing mucous Rapid shallow breathing Sometimes wake up choking or gasping for breath Yawns frequently Sometimes hyperventilates Frequent chest colds Cardiovascular Slow, strong pulse Fast, light pulse History of PID, cervicitis Frequent physical activity Warm bodied Menses early w/altitude change Cold bodied Sometimes dizzy or faint Hands warm, sweaty Frequent candida type infections Hands cold, clammy or dry Palpitations either as an adolescent or before menses Hypertension, but responds to diuretics Hypertension, does not respond to diuretics General Aluminum cooking vessels Impaired hearing Awakens, can't go back to sleep Increase in weight (recent) Bad dreams Lack of sensation somewhere in the body Blurred vision Likes depressants Brown spots, bronzing of skin Likes stimulants Bruises easily Lower back pain Can't gain weight Frequent muscle cramps Can't lose weight Nails split, brittle Can't get started without coffee Nails weak, ridges Chemical or spray poisoning Nose bleeds frequently Chronic fatigue, depression Pollution heavy in work or home environment Cry easily without seeming cause Ringing in ears Depressed for long periods Pulse speeds up after meals Earaches Sensitive to cold weather Eat often or else faint/nervous Sensitive to hot weather Eyes often red or inflamed Sensitive to high humidity Face and eyes get puffy Sensitive to low humidity Facial twitches Sexual desire decreased Gum problems Sexual desire increased Headaches Stuffy nose during the day Headaches in the morning, but wear off Stuffy nose in the evening or night Heart palpitations when hungry Seems to have a tendency towards anemia Heart palpitations after eating Tremors in hands or neck Highly emotional Varicose veins Highly controlled Weight gain in upper arms, shoulders, or back of neck Thank you!
