Consulting Questionnaire

The Herb'n Muslim

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Consulting Questionnaire

Please make payment by clicking on the "Payments" link above, fill out the form below and press the send button at the bottom of the page to receive your consultation. After receiving your payment Kristie Karima Burns, MH, ND will respond to your form by asking you further questions and perhaps sending you a second, more in-depth form, if needed.

Name?
Age?
Who referred you to us?
Why are you seeking a consultation?
E-mail address?
Female or Male?
Do you live in the city, suburbs or country?
Do you live in a house,apartment or other?
Is your dwelling sunny or dark?
Who do you live with?
Do you have pets? Which kind?
What kind of water do you drink?
Do you bathe in filtered water?
following is a list of neighborhood annoyances. List in the box any of the following you have:Loud dogs, airport nearby, loud neighbor(s), high voltage power lines, factory nearby, highway nearby, heavy traffic nearby, near a farm that uses chemicals, other:
Height?
Weight?
Known Allergies?
The following is a list of some common food items. Please list the ones that are included in your DAILY or USUAL diet (do not include those you have only on special occasions or very rarely): Red meat, fish, poultry, fruits, vegetables, raw foods, grains, nuts, seeds, fermented foods, butter, milk, cheese, yogurt, sugar, honey, baked goods, desserts, coffee, black tea, herbal tea, alcohol, vitamins, protein supplements, food supplements, cigarettes, white flour, canned foods, frozen foods, whole wheat flour, pasta, white rice, brown rice:
Which items do you consume most often?
Do you follow any special or restricted diet at this time?
What would you like to change about your eating habits?
Do you eat out often? Which restaurants and how often?
What times do you eat?
Are your meals relaxed or stressful times?
Who cooks at your home?
Occupation?
Married?
How many children do you have?
What music do you listen to?
What is your favorite color?
If you are a woman: Are you pregnant or trying to get pregnant?
Are you seeing a physician or health care practitioner for any reason? If yes, then why?
How many times do you urinate in one day?
How many times do you urinate at night?
How many bowel movements do you have each 24 hour period?
Are your bowel movements hard, dry, soft, runny or constipated?
Following is a list of health problems. Please list in the box any which apply to you: high or low blood pressure, pain in the heart, poor circulation, swelling ankles, previous stroke or heart murmur, backache, broken bones, mobility restrictions, arthritis, bursitis, asthma, earaches, eye pains, dry or wet eyes, failing vision, hay fever, sinus congestion, sore throat, tonsils, hearing loss, excessive urination, water retention, burning urine, kidney stones, lower back pain, dark circles under eyes, itchy ears or eyes, emotional insecurity, boils, bruises, dryness, itching, varicose veins, skin eruptions, chest pain, difficulty breathing, cough, tuberculosis, congestion, belching, colitis, constipation, abdominal pain, liver problems, gallstones, ulcers, indigestion:
Following is a list of health problems. Please list in the box any which apply to your immediate family (mother, father, sister or brother) : high or low blood pressure, pain in the heart, poor circulation, swelling ankles, previous stroke or heart murmur, backache, broken bones, mobility restrictions, arthritis, bursitis, asthma, earaches, eye pains, dry or wet eyes, failing vision, hay fever, sinus congestion, sore throat, tonsils, hearing loss, excessive urination, water retention, burning urine, kidney stones, lower back pain, dark circles under eyes, itchy ears or eyes, emotional insecurity, boils, bruises, dryness, itching, varicose veins, skin eruptions, chest pain, difficulty breathing, cough, tuberculosis, congestion, belching, colitis, constipation, abdominal pain, liver problems, gallstones, ulcers, indigestion.
Following is a list of health problems. Please list in the box any which apply to your extended family (Grandmother, grandfather, aunt or uncles) : high or low blood pressure, pain in the heart, poor circulation, swelling ankles, previous stroke or heart murmur, backache, broken bones, mobility restrictions, arthritis, bursitis, asthma, earaches, eye pains, dry or wet eyes, failing vision, hay fever, sinus congestion, sore throat, tonsils, hearing loss, excessive urination, water retention, burning urine, kidney stones, lower back pain, dark circles under eyes, itchy ears or eyes, emotional insecurity, boils, bruises, dryness, itching, varicose veins, skin eruptions, chest pain, difficulty breathing, cough, tuberculosis, congestion, belching, colitis, constipation, abdominal pain, liver problems, gallstones, ulcers, indigestion.
Are you allergic to any medications? Which ones?
Which medications are you taking now?
What vitamins/supplements do you take now?
Have you had any major operations? Accidents?
Have you had any hospitalizations? For what reason?
If you are female the following is a list of health problems commonly experienced by females. Please list any which you are experiencing NOW: Fibroids, Uterine Cysts, Endometriosis, cervical dysplasia, pelvic pain, painful intercourse, swelling of hands, feet or ankles, vaginal infections, breast pain, breast lump, vaginal itching, difficulty in conceiving, general fatigue, anemia, headaches, pelvic inflammatory disease, infertility, genital herpes, shortness of breath, irregular menstrual cycles, heavy menstrual bleeding, bleeding between cycles, absence of a menstrual cycle, dramatic mood swings around your menstrual cycle, hot flashes, dry vaginal lining, osteoporosis, break-though bleeding, ERT therapy
The following is a list of some common physical activities. Which do you participate in and for how long each week/day?: Sitting at a desk, sitting in a car, jogging/running, calisthenics, aerobics, swimming, weight lifting, walking, standing, yoga, tai chi, hiking, bike riding, horseback riding, tennis, bending/lifting, gardening, skiing, other.
If you are a woman: Have you used birth control ? For how long?
Are you able to express your feelings and emotions?
Are you happy with your job?
Are you happy in your marriage?
If you are interviewing a child for this form ask them if they are happy at school:
What is the one thing you could change in your life now if you could change anything?
Are you a nervous person? What makes you nervous?
Do you sleep well?
Which of the following feelings is predominate in your life? List, in order of frequency which apply: Joy, happiness, anger, sadness, fear, sympathy, worry, depression, negative feelings, positive feelings, other.
The following is a list of experiences. Please circle which ones you have experienced in the past seven years and when: divorce, loss of a loved one, loss of a job, change of residence, injury, violation of property or self, death of a close relative, death of close friend, death of acquaintance or distant relative, other. Please list the most current dates in which one of these occurred:
Are you happy with your current finances?
Do you experience lack of energy?
Do you experience frequent illness?
Do you experience body odor or bad breath?
Do you have difficulty digesting foods?
Do you consume red meat frequently?
Do you have female concerns?
Do you use antibiotics frequently?
Do you have frequent mood swings?
Do you have food allergies?
Do you have bags under your eyes?
Are you smoking or around those that smoke?
Do you have poor concentration or memory?
Do you consume a lot of alcohol?
Do you have poor resistance to disease?
Do you experience belching or gas after meals?
Do you experience a stressful lifestyle?
Do you have skin or complexion problems?
Do you have a craving for sweets or processed foods?
Do you consume dairy products regularly?
Are you feeling low, uninterested or depressed?
Do you experience too little sleep or restless sleep?
Do you have menopausal concerns?
Do you have frequent urinary concerns?
Do you experience hair loss?
Do you have sore or painful joints?
Do you have difficulty maintaining ideal weight?
Do you have low endurance during an activity?
Do you have poor eating habits?
Do you have irregular or infrequent bowel movements?
Do you have low sex drive?
Do you experience lack of appetite?
Do you have brittle or easily broken fingernails?
Do you have dry, damaged or dull hair?
Do you have a high-fat diet?
Do you feel unsettled, apprehensive or pressured?
Do you have a low-fiber diet?
Do you have muscle cramps?
Do you have exposure to air pollution?
Do you have heavy caffeine consumption?
Are you feeling out of control?
Do you have food/chemical sensitivities?
Do you have problems with yeast/fungus?
Do you have any structural weaknesses?
Do you experience excessive worry?
Are you easily irritated or angered?
Do you exercize too little?
Do you have excessive mucus?