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Please Provide Information About Your Symptoms

Symptom 1

Timing of Symptom

Severity

Mild
Moderate
Severe

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Symptom 2

Timing of Symptom

Severity

Mild
Moderate
Severe

Symptom 3

Timing of Symptom

Severity

Mild
Moderate
Severe

Please list any additional symptoms or diagnosis

Do you have any known allergies; herbs, food, etc.? If so, please list below

Which types of products would you prefer?

Tea
Tincture
Powdered Herbs
Honey Paste (powdered herbs in honey)
Topical Remedy

Constitution Questions. Check all that apply.

I experience cold hands and feet
I sweat easily
I have dry, brittle hair, skin or nails
I am prone to nervousness, restlessness or worry
My body temperature is consistanty warm
My appetite is strong
I am prone to inflammation
My digestion is slow
I am prone to lethargy
I am prone to anger, irritation or intensity
I don’t tolerate hot weather
I don’t tolerate windy conditions
I don’t tolerate cold weather
I have moist, oily skin
I am prone to swelling, puffiness or stagnation
My appetite is inconsistant
If I miss a meal, I get hangry (irritated)
I experience gas, bloating or heartburn regularly
I feel sleepy after meals
I prefer raw foods
I prefer warm, cooked foods
I have steady energy all day
I have energy spikes or inconsistant energy
I am fatigued most days
I am a light sleeper
I often wake in the night too hot or thirsty
I could sleep all the time, I love it and it is easy to do
I have a thinner build
I have a fuller, thicker body type
I have a muscular build
I gain and lose weight easily
I have a hard time losing weight
I don’t gain weight easily
I prefer stillness
I prefer action and movement
I wake feeling rested
I tire easily
My favorite season is Winter
My favorite season is Summer
My favorite season is Spring
My favorite season is Autumn
I stay calm in stressful situations
I adapt easily to changes
I feel most energized in the morning when I get up
I feel most energized midday
I feel most energized in the evening
I shutdown in stressful situations
I get anxious easily
I enjoy spicy foods
I like oily and creamy foods
I like satly, crunchy foods
I like sweets

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