Three Treasures Wellness Consultation

Client Questionnaire

This questionnaire must be filled out as thoroughly as possible for evaluation by our professional licensed herbalists. Your responses provide our herbalists with very important information allowing our practitioners of state-of-the-art Chinese tonic herbalism broad insight into your constitution (genotype/phenotype), health status, conditions, Yin-Yang balance, the state of your Five Elemental Energies (which illuminates how your system is working), the status of your Three Treasures (Jing, Qi and Shen), the health of your Meridian System, and the vitality of your “innate capacity” and “resilience,” as well as an understanding of your history and goals. (note to herbalists: soon, we will be able to offer an accurate “biological age” – as opposed to chronological age – after the evaluation). A well-answered questionnaire will allow our herbalists to make professional herbal, dietary and lifestyle recommendations that are very safe and highly effective when applied as directed by our herbalists, and properly by the client.

You may wonder why we are asking so many questions. It is for you, and will eventually save time and money. By answering this long questionnaire, you are saving hours of inquiry time by hour herbalists, who will need this information to develop your fully holistic longevity program.

Why do we inquire into the pharmaceuticals you are consuming? We are aware that some herbs, foods and lifestyle choices can interact or interfere with pharmaceutical prescriptions, and vice versa. For this reason, we will be including questions related to signs and symptoms that may require medications and we will be asking what medications you have been prescribed by physicians to address these conditions. This is important because Dragon Herbs takes a strict health promoting approach that can work for everyone, so long as we have full information on the client. For example, those on blood thinning medications should use certain herbs with caution or not at all so as not to interfere with the medical protocol. The herbalist will know how to avoid conflict. The same is true for sugar regulation, cardiovascular regulation, and so on. Please answer these questions to the best of your ability so that our herbalist can make accurate herbal, dietary and lifestyle suggestions, and so that you can benefit safely and speedily from tonic herbs, superfoods and appropriate lifestyle changes. Generally, tonic herbs have mild yet profound regulatory effects, and are considered safe when used as directed.

Prior to the consultation, we advise all clients to read “The Introduction to Chinese Tonic Herbalism,” which is available free online at dragonherbs.com/intro. This convenient flipbook explains the traditional approach to establishing glowing health employed by Dragon Herbs. It is also available in the Dragon Herbs Catalog 2020, pages 99-116.

  

Basic Information

Fields marked with * must be filled in.
*First Name:
*Last Name:
DH Account#:
Birth Date (MM/DD/YYYY):
Gender:	Male Female Other
Height:
Weight:
Location:	Please describe any climatic conditions that define your area
How did you hear about us:	Word of mouth Post from a friend/family on Social Media Search Engine Facebook Instagram Other

  

Your Goals

Health concern(s):	Do you have a specific goal(s) or health concern(s) you would like to address with an herbalist to improve upon? No Yes (briefly specify):
What are your health-and-wellness goals?	Examples: Sleep better, boost energy, stress relief, improve sex drive, enhance focus, overcome sadness, reduce stress, lose weight, gain weight Short-term (days, weeks or months): Mid-term (a few years): Long-term (decades):
What are your life goals?	Be grand, dream big
What are your primary health concerns?