Frank A Curto Jr., Master Herbalist
                                 
      
                 
 
AADP Board Certified Holistic Health Practitioner
 
 
Questionaire
Wellness & Lifestyle Questionnaire
*Instructions: Complete questionnaire by filling in the blank spaces with your information and checking the applicable boxes. Once complete, check the box following the consent statement and click on the submit button.

 

Contact Information
Date:
First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State:
Daytime Phone:
Evening Phone:
Email:

Client Profile
Age:

Sex:

Male

 

Female

Height:
Weight:
Living Situation: 

Alone

 

Friends

 

Partner

 

Spouse

 

Parents

 

Children

 

Pets

What are your major health concerns for this consultation?:
Please list any other health care providers or consultants you are currently working with:
Please list any current health conditions diagnosed by a medical doctor:
When was your last physical exam?:
Please list all herbs, vitamins, and dietary supplements you are currently taking, including dosage and frequency:
List all medications you are currently taking (including aspirin, antacids, etc.) indicating whether they are over -the-counter (OTC) or Prescription, including dosage and frequency:
List all medications, herbs, foods, environmental factors, to which you have a know allergy:
Dietary Information
Describe below your typical meals. Please be specific as possible. For example, instead of "oil" note type of oil, such as olive, corn, etc. Instead of "bread" list whether white or whole grain, etc. Instead of "vegetables" list the type of vegetable, how prepared, canned, frozen, fresh, etc. Please include beverages, type and quantity ( two cups of orange juice, one cup of coffee-with cream/sugar, etc.)
Breakfast:
Morning Snack(s):
Lunch:
Afternoon snack(s):
Dinner:
PM snack(s):
Daily water consumption (number of glasses/day):
Any recurring food cravings (such as salt, starch, sugar, chocolate, etc.) please list as many as possible including time of day or month:
 Family History
Please describe any relevant or major health related issues: ( cancer, mental illness, diabetes, heart disease, etc.)
Mother:
Father:
Siblings:
Maternal Grandparents:
Paternal Grandparents:
Medical History
List all major health problems including operations:
Problem/Year:
General Health
Check all that apply to you

 Cardiovascular:

High blood pressure

 

Low blood pressure

 

Pain in heart

 

Poor circulation

 

Swelling

 

Stroke/murmur

 Skin

Boils

 

Bruises

 

Dryness

 

Itching

 

Varicose veins

 

Skin eruptions

 Muscles/Joints

Backache

 

Broken bones

 

Limited mobility

 

Arthritis

 

Bursitis

 

Weakness

 Respiratory

Chest pain

 

Difficulty breathing

 

Cough

 

Tuberculosis

 

Congestion

 

Itchy ears/eyes

 

Asthma

 

Coughing up blood

 Urinary/Kidney

Excessive urination

 

Water retention

 

Burning urine

 

Kidney stones

 

Lower back pain

 

Wheezing

 

Circles under eyes

 

Blood in urine

 Gastro-Intestinal

Belching

 

Colitis

 

Constipation

 

Abdominal Pain

 

Liver Disorders

 

Gallstones

 

Ulcers

 

Digestive troubles

Eyes, Ears, Nose and Throat

Ear aches

 

Hay fever

 

Sore throat

 

Canker sores

 

Eyes pains

 

Sinus infections

 

Tonsils

 

Nosebleeds

 

Failing vision

 

Sinus congestion

 

Hearing loss

 

Difficulty breathing

General 

Fatigue

 

Excessive thirst

 

Difficulty sleeping

 

Night sweats

 

Loss of appetite

 

Irritability

 

Fever

 

Always hungry

 

Cold hands & feet

Male reproductive 

Burning/discharge

 

Painful testicles

 

Lumps/sweeling of testicles

 

Vasectomy

Female reproductive
Age of first period:

 

Heavy bleeding

 

Vaginal discharge

 

Painful intercourse

 

Breast pain

 

Infertility

 

Mood swings

 

Irregular cycles

 

Blood clots

 

Vaginal itching

 

Vaginal dryness

 

Breast lumps

 

Genitial herpes

 

PMS

 

Pre-menopausal

 

Menopause

 

Pains/cramps

 

Pelvic pain

 

Anemia

 

Hot flashes

 

Not able to conceive

Contraceptive/Pregnancy History

Birth control pills/patch

 

Diaphragm

 

Cervical Cap

 

Rhythm-method

 

Condoms

 

Spermicides

 

I.U.D.

 

Mucous-method

Please list each pregnancy you have had, including miscarriages:

Fertility lens



Current state of emotions & spiritual well-being

Please check all those describe you:
 

I am often not able to express my emotions

 

I am dissatisfied with my job

 

I am often stressed out and not able to cope properly

 

Even though I'm in a relationship, I often feel lonely

 

I often feel anxious & nervous for no good reason

 

I don't sleep well at night & have a hard time waking in the morning

 

I often suffer from bad dreams & nightmares

 

There are many things that I'd like to change in my life but just don't have the means

 

I have very low energy & often feel exhausted mentally & physically

 

I don't enjoy my work and would rather be doing something else

 

I find my children irritating & hard to relate to

 

I have very few hobbies

 

I often feel depressed for no reason

 

I often become angry with people and feel guilty about it later

 

I have a hard time letting go of the past

 

I don't look towards the future with much enthusiasm

 

I am not able to concentrate for extended periods of time

 

My outlook is more negative than positive

 

I spend a great deal of time worrying about what people think about me





 

I tend to see the good in people

 

I have a great sense of humor and love a good joke

 

I receive great joy from my family

 

My outlook on life is positive

 

My job uses all my greatest talent

 

I have plenty of energy to do all the things I want

 

I sleep well at night & feel rested in the morning

 

I can concentrate on the task at hand for as long as it takes

 

I have a strong spiritual faith

 

I am able to express anger constructively

 

I practice meditation or other relxation techniques

 

I try to maintain peace of mind & tranquility

 

I have many close friends that I can always count on

 

I accept full responsibility for my actions

 

I trust my intuition & believe that things happen for a reason

 

I do not harbor any resentment from the past

 

I can feel completely fulfilled even if I'm alone

 

I have many hobbies & interests to keep me preoccupied

 

How I see myself is more important than how others see me

 

I often go out of my way to help others

Please list the approximate dates & describe the nature of any traumatic experiences you have had in the past 7 years (divorce, surgery, end of relationship, loss of job, change of residence, injury, death of a loved one, etc.):


Lifestyle Habits
 Do you engage in regular physical activity?

Yes

 

No

If yes, how often?:
For how many minutes?:
 Do you smoke tobacco?

Yes

 

No

If yes, how much (packs/cigarettes per day)?:
Do you drink alcohol? 

Yes

 

No

If yes, how much?:
How often?:
Do you drink coffee and/or caffeinated beverages? 

Yes

 

No

If yes, how much?:
How often?:
How many hours of television do you watch per week?:
Do you use artificial sweetners? 

Yes

 

No

Comments:Please use the space below to add comments or any other information about yourself that you think will be helpful:




STATEMENT OF CONSENT
I request that Frank Curto, MH perform a consultation and set up a program for the purpose of enhancing my health and well being. I understand that Frank Curto has a Master Herbalist certification from the Global College of Natural Medicine, an accredited school in California, board certification from the American Association of Drugless Practitioners as a Holistic Health Practitioner and is ordained in the Ministry of Herbalism by the Church of the Universal Light. I understand that this consultation is not intended as a diagnosis, prescription, or treatment for any disease, physical or mental. It is also not intended as a substitute for regular medical care.

ARTICLE IX, U.S. CONSTITUTION “The
enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people.” Under the ninth Amendment to the Constitution of the United States of American, I retain the right to freedom of choice in health care (or psychological services, or educational services, etc.) This includes the right to choose my diet, and to obtain, purchase and use any therapy, regimen, modality, remedy, or product recommended by the therapist, doctor or any practitioner of my choice. The enumeration in this declaration of these shall not be construed to deny or disparage other rights retained by me, or my right to amend this declaration at any time.

CONSTRUCTIVE NOTICE
Notice is hereby given to any person who receives a copy of this declaration and who, acting under the color of law, intentionally interferes with the free exercise of the rights retained by me under the First and Ninth Amendment, as enumerated in this declaration, that they may be in violation of my civil and constitutional rights, Title 42, U.S.C. 1983 et seq. And Title 18, Section 241.

 I have read the consent statement and agree with the terms

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