SKY ISLAND HERBALS

MY"
Name:

HEALTH/LIFESTYLE ASSESSMENT FORM

____________________ Age:__________Weight: ____________ Height: __________

Please describe in detail your specific health concern. When was the first time that you noticed the condition, what
if anything makes it better or worse and are there any factors that you suspect may have played a role in its onset
and its continuation:

Are there any other health issues that are troubling you: ______________________
Are you presently under the care of a physician or other alternative health care practitioner and if so for what
problem:__________________________________________________________________________________
Currently, are there any significant stress situations in your life: ______________________________________
Do you have any allergies to drugs, herbs, foods, animals or other: _______________
How many hours do you sleep daily (average, include naps):__________Do you awaken feeling rested?
Do you smoke?

If yes, how much?__________If no, are you exposed to second hand smoke?

How many hours a day do you watch T.V.?__________read?_________drive?________do computer work?

Do you currently use any of the following (how often, how much, how long):
Alcohol____________________________________ Tobacco____________________________
Hormones__________________________________ Coffee___________________
Cortisone___________________________________ Laxatives________________
S e d a t i v e s
A n t a c i d s _________________________
A n t i b i o t i c s
P a i n M e d i c a t i o n _______________________
V i t a m i n s
H e r b s / H o m e o p a t h i c _______________________
Other