Online Assessment

Legal Name:

Preferred Name:

Date of Birth:

Home Address:

Home Phone Number:

Business / Cell Number:

Occupation:

Number of hours per week:

Sex

Male

Female

Other

I identify my gender as...

Male

Female

Trans

Other

Emergency Contact:

Reason for appointment:

How long have you had this condition?

Is it getting worse?

What seemed to be the initial cause?

What makes it better?

What makes it worse?

Are you under the care of a physician now?

Yes

If yes, what are you being treated for?

Who is your physician? (Name, contact number)

Are you receiving any other therapies?

Have you received a diagnosis for the symptoms you’re experiencing? If yes, what was the diagnosis the date it was given?

What is the #1 symptom you experience and how does it affect you? Proceed with #2 and #3 symptom as well:

How long have you been experiencing these symptoms?

Were there any unique circumstances surrounding the onset of your illness? (Examples: travel, physical injury, emotional trauma, stress, infection, change in an important personal relationship, etc.)

Please list any relevant medical tests you’ve had done (Examples: blood tests, stool tests, x-rays, CT scans, colonoscopies, endoscopes, ultrasound, etc.)

Please list any medications, past or present, that you’ve taken for this condition:

Have you tried any alternative or holistic therapies for your condition?

Have you tried any dietary changes for your condition?

Please describe your current diet, and give examples of breakfast, lunch and dinner.

Do you have any food allergies?

Do you have any food cravings?

Please list any supplements you’ve tried in the past for this condition, as well as any supplements you are currently taking.

Do you smoke cigarettes or consume alcohol?

Have you tried cannabis products such as THC or CBD for your symptoms?

Describe your sleep patterns as well as the number of hours you typically sleep.

Generally, what is the colour of your urine? How frequently do you urinate?

How many bowel movements per day do you have? Please describe the nature of your stool. (i.e. formed, loose, diarrhea, constipation, color, tenesmus, narrow, urgent, etc).

Is there blood or mucous in the stool? If so, is there more blood or more mucous? If you are bleeding, approximately how much blood are you losing?

Are you experiencing pain? If so where and how often? Describe the sensation of pain, where it is located. Does anything make it better or worse?

Do you have any gas or bloating? Is the gas very strong smelling or average?

Any heartburn?

Do you know your usual blood pressure?

For Woman:

How many days do you bleed?

Is your period light, heavy, or average?

Do you ever see clots in your blood?

Is your menstrual blood lighter or darker in color?

Do you ever experience PMS?

Do you get menstrual cramps?

Are you currently taking birth control?

Have you taken it in the past? If so, for how long?

Any skin issues?

Do you have a sensitivity to chemicals? (Examples: household cleaners, perfumes and colognes, artificial fragrances, chlorine in swimming pools, air pollution, etc.)

On a scale of 1-10, what is your energy level?

Do you often experience being thirsty? How much water do you drink? Do you frequently experience a dry mouth or throat?

Do you ever experience shortness of breath?

Does your body typically run hot or cold?

Do you ever have red flushing in your face or eyes?

Do you have any allergies? Please describe:

Please list any other diagnosed medical conditions:

Have you ever had any surgeries?

Do you ever feel dizzy?

What would you like to accomplish working with me? Describe your goals.

In what ways do you feel that your illness is affecting your psychological state or mood?

Do you exercise? If so, how often and what kind of exercise(s)?

What is your stress level like on a daily basis?

Have you ever had acupuncture or Chinese herbal medicine before? If so, what were you being treated for? What was the result?

What are your hobbies / pleasures?

Do you have children? A spouse/partner?

Do you feel like your primary relationships are healthy?

What is the #1 thing you love about yourself?

Is there anything else you would like to add?

Consent Agreement

I give consent to Jason Brien, R. TCMP to provide holistic health medical counseling to myself or to the client for which I am legally responsible. The consult will provide information and guidance about health factors within my control: my diet, nutrition and lifestyle. I understand that Jason Brien is not an MD and does not dispense medical advice, nor will he diagnose or treat any medical condition, but will provide nutritional support and holistic education for an already diagnosed condition. He provides information to enhance my knowledge of health through the use of whole foods, dietary supplements, herbs and emotional awareness. While nutritional and botanical support can be an important complement to my medical care, I understand these services are not a substitute for medical care. Methods of nutritional evaluation or testing made available to me are not intended to diagnose disease. Rather, these assessment tests are intended as a guide to developing an appropriate health support program for me, and to monitor my progress in achieving my goals. Medical records, personal information and history divulged in session to Jason Brien will be kept confidential, unless I consent to sharing my medical information.

I agree to hold Jason Brien harmless for claims or damages in connection with our work together. This is a contract between myself and Jason Brien and I understand that it is also a release of potential liability.

By writing my name below and checking “Agree”, I agree to these terms.

First Name*:

Last Name*:

Email Address*:

DateDec 5, 2023

Agree

*Denotes mandatory field

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