Consultation Questionnaire Prescheduled Private Phone consultations are available with Medical Herbalist, David Kukkola. This Questionnaire needs to be filled out and received prior to the private phone consultation. Please provide a preferred day and time. We will arrange a time that can work for all of us. One-hour (first visit) $150 plus herb cost (includes nutritional guidance) Subsequent 30 min: $50 plus herb cost. A sliding scale is available for people who are on a limited income. Health is a fundamental birth right. Confidential Health ProfilePlease enable JavaScript in your browser to complete this form.Name *FirstLastDate of BirthLayoutHeightWeightMailing AddressAddress Line 1Address Line 2CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutPhoneEmail *Preferred Consultation Date and Time *Health ConcernsOverall Physical HealthDescribe Your Major Health Concerns and Medical HistoryCurrent Physical Health ConcernsLayoutDate of Last Complete Blood PanelIf requested, can you email us a copy of your last blood panel for review?Any Issues with the following? (Select all that apply)Any Issues with the following:Eyes:Get red frequentlyStyesFloatersBright Light hurts your eyesSinuses:AllergiesMouth:Sores in the mouth or gumsHerpesSkin:Flushed FaceDryOilyAcneAcne location?Ears:RingingRinging FrequentlyHigh Pitch RingingLow Pitch RingingTeeth:LooseGum DiseaseHair:OilyDryDandruffFingernails/Toenails:SoftBrittleRidgesGrow slowlyFungusAthlete's FootList All Major Illnesses/Surgeries with DatesList all Injuries/Joint/Body Pain with DatesAre any of these physical conditions acute or chronic?LayoutHeadaches:AcuteChronicHeadachesMigrainesWhat part of the head:Frequency:Are you currently taking any pain medications, which ones, how long and for what reason?What vitamin supplements and/or herbal supplements are you currently taking?EnergyEnergy:Describe Your Energy Level:HighModerateLowExhaustion:MentalPhysicalBest Time of Day:Worst Time of Day:SleepSleepHow is your sleep quality? (Select all that apply)Sleep is goodSleep is problematicHard to fall asleepInsomniaWorse when stressedNot Eating or SleepingDo you experience any of the following while sleeping? (Select all that apply)DreamsNightmaresFrequent Waking with NightmaresWaking in the Early Hours of the MorningWaking Up FrequentlyWaking Up Between 1am-3amDream-Disturbed SleepGrinding Your TeethClenching Your JawWhat is your feeling when you first wake-up?Digestion and DietHow is your digestion and appetite, in general? (Select all that apply)Normal appetiteGet hungry frequentlyGet full easilyDairy intoleranceGluten intoleranceDaily stoolFrequent stoolConstipatedDiarrheaIrregular stoolCramping/BloatedBlood Sugar/Hypo or HyperglycemiaWhich foods upset your stomach?Dietary Habits, Describe:Breakfast:Lunch:Dinner:Snacks:Beverages:Urination, Describe:Urination, Describe:Unusual Urination Frequency, Day and Night:Color of first urination in the morning:Prostate/Hyperplasia:Color/Odor:Bladder Infections/UTI:Vaginal/Yeast Infections:Body TemperatureBody Temperature: Do you experience any off the following? (Select all that apply)Feel warmFeel coldWarm head & Cold feetCold Fingertips & ToesCold Hands & FeetHot Hands & FeetFeverish/Flush in the afternoon or eveningNight SweatsDay SweatsSweat easily without exertionDifficult to SweatDry Mouth/LipsDry SkinDryness in other parts of the bodyThirstThirst: Do you experience any off the following? (Select all that apply)Drink water dailyGet thirsty frequentlyLack of thirstWater does not quench thirstDry mouth with no desire to drinkPrefer to drink warm drinksPrefer to drink cold drinksWomenDescribe your monthly cycle (menstruation): LayoutMonthly cycleCrampsColor of BloodClotsGenital HerpesMiscarriagesPre- or Post-MenopausalPMSHeavy BleedingFertility IssuesChildrenBirth Control/IUDDescribe your symptomsAre you still experiencing any of these symptoms?MenMen: Do you experience any of the following? (Select all that apply)Prostate IssuesGenital HerpesEDPremature EjaculationFertility IssuesMental WellnessDescribe yourself mentally/emotionally:What mental/emotional issues are you struggling with?Are there any emotions that are difficult to manage or express?Have you been getting counseling from a psychologist or therapist?Has the counseling been beneficial for your mental health?Clinical ManifestationsLayoutDo you experience any of the following symptoms? (Select all that apply)Tendency to sigh or frequent yawningMelancholyDepressionSuffocating/Tightness in chestBody tensionStressMoodinessIrritabilityInappropriate AngerIndecisivenessSensation of something caught in throatHeart PalpitationsEasily startledRestlessnessAgitationDo you experience any of the following symptoms? (Select all that apply)AnxietyExcessive TalkingTimid/ShyAlternating Excessive Talking and TimidPoor memoryAbsent-mindednessFrequent feelings of extreme sadness with an urge to cryInability to control emotionsQuick temperShouting/AggressiveUnable to answer questionsRash/impulsive behaviorUnable to rest or sit quietlyDesire to climb high placesHow long have you been dealing with your mental health?Have any of these issues improved or worsened over time?What medications are you currently taking, and for what reason?How long have you been taking each medication?Are you compliant in taking your medications, if prescribed?Do you feel that the medications have helped you mentally/emotionally?Are you experiencing any side effect from the medications?Addiction RecoveryWhat substance addictions are you in recovery for?How long have you been dealing with addiction?Was this a progressive addiction?What do you feel caused this addiction, physically or emotionally?Have you taken any steps for recovery, and what are they?OverviewDescribe your current health concerns and how they might be interwoven with your overall emotional, mental, and spiritual state of being:GoalsWhat are your immediate goals regarding your overall health?Submit
