Constitutional Health Questionnaire

This is a contact form for requesting a consultation with me as an herbalist and health and wellness coach. I do this on a no-obligation, donation basis.

All your information is kept in strict confidence and your form is deleted from this site as soon as I receive it.

I use your responses to determine which herbs and natural remedies (and possibly other healing modes) will work best for you.

When your questionnaire arrives in my email box I will go over it carefully and respond with recommendations, and we can set an appointment time by phone if needed.

Be sure to read the Constitutional Strength page (opens in new tab) and estimate it (first question below).

Part 1 – basic body patterns

Rate these 1-10 (1 is poorest, 10 is best). Comment as needed.

Constitutional strength(required)

Physical strength (lifting, gripping, squatting, pushing)(required)

Energy level(required)

Stamina: does your energy fade partway through the day? When?(required)

Body warmth: do you get chilled at all? Heat up too easily?(required)

Circulation-extremities: hands/feet warm/cold?(required)

Appetite/digestion: How many meals per day? How well do you digest? Any foods you must avoid?(required)

Food cravings / preferences

Eliminations:

bowel movements: average daily number and ease or difficulty(required)

urination: frequency and typical color(required)

perspiration: do you perspire easily?(required)

How much water do you drink daily?
What other types of beverages?

fluid intake(required)

Sleep: how many hours per night average?
Do you usually wake refreshed?
How often is sleep interrupted and about what time?

Sleep patterns(required)

Part 2 – history and constitutional patterns

What best describes your personality:
(a) competitive, fighting spirit, survivor, not afraid of confrontation;
(b) sensitive, empathic, reactive, avoids confrontation;
(c) steady, stability-oriented, organized, reasonable.

Personality: A, B, or C? Describe further if needed(required)

Any chronic skin condition?
If so, what age did it start?
Where on your body?
Describe well.

Skin conditions

Any other chronic, life-long condition?
Describe.

Chronic conditions

Do you have a paradoxical reaction to drugs or stimulants? (caffeine calms you down, sedatives perk you up, etc)
Or do you have a high sensitivity to drugs?

Response to drugs/stimulants(required)

Any injuries to head or spine?
When?
Describe each, no matter how minor or far back — including surgical operations.

Injuries to head/spine

MEDICAL – describe as needed

Do you have any medical diagnoses for conditions you’ve not overcome?

Current medical diagnoses

Do you have past medical diagnoses that you’ve overcome?

Past medical diagnoses

Major medical procedures:

Major medical procedures

Any problem drugs that have changed your health?

Problem drugs

Mind/temperament
What is the mental state or emotion you have the most trouble with?

Mental states/emotions(required)

What part(s) of your body give you the most trouble. Describe.

Body troubles(required)

What type of aches/pain(s) do you experience?
Where?
Rate each with intensity level (1-10).

Aches/pains

Consult by phone – if in US or Canada.
Please give your phone number, time zone, and days/times you are available.

Phone contact / times

Name(required)

Email(required)

Submit

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I appreciate any feedback on this questionnaire. If you have any ideas on how it can be improved, please let me know. Thank you.

Donation options for your reference.
I recommend everyone wait until they get positive results before donating. No obligation. You owe me nothing if I cannot help you.

– Facebook messenger pay. Find me there as Kannon McAfee. Send friend request or message me first.
– Paypal: ask me for the email on my account
– Venmo (wife’s): Heather-McAfee-8
– Cashapp (wife’s): $HRM197