Case Studies: Student must complete 5 case studies as instructed by course
materials. Fill out form below for 5 different people (imaginary is okay).
Master Herbalist Questionnaire
Date: _____________________
Name: _________________________________ Age: ______ Birth date:_____________
Address: ________________________________________________________________
Home Phone: _________________________ Work Phone:________________________
Height: _________ Weight: _________ 1 year ago:__________ 5 years ago:_________
Occupation: _______________________________________ Full Time Part Time
Living situation: Alone Friends Partner Spouse Parents Children Pets
What are your major health concerns and intentions for your visit today?
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Please list any other health care providers or consultants you are currently working with:
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Please list any current health conditions diagnosed by a medical doctor:
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Please use this form
as a source of
reference when
conducting your
Case-Studies.
Treat this part as information only as you are not to treat or prescribe treatment for any specific diseases
It is important to know if the client is receiving treatment from other practitioners and what these entail
Since legally you are not allowed to diagnose disease, it is helpful to get one from an MD
When was your last physical exam?
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Please list all herbs, vitamins, and dietary supplements you are currently taking, includingdosage and frequency:
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List all medications you are currently taking (including aspirin, antacids, etc.) indicatingwhether they are over the counter (OTC) or Prescription, including dosage and frequency:
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List all medications, herbs, foods, environmental factors, to which you have a knownallergy:
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This is important information to have in order to avoid any interactions. Please use your textbook as well as the A-Z Guide to Drug-Herb-Vitamin Interactions for reference
This is important information to have in order to avoid any interactions. Please use your textbook as well as the A-Z Guide to Drug-Herb-Vitamin Interactions for reference
You have to keep these in mind when making suggestions. For example, someone allergic to ragweed may have a reaction to Chamomile
DIETARY INFORMATION
Describe below your typical meals. Please be as 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, or fresh, etc. Please include all beverages, type and quantity (two cups of orange juice, one cup of coffee, etc.,).
Breakfast:
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Morning snack(s):
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Lunch:
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Afternoon snack(s):
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Refer to the Nutritional Guidelines booklet. Keep in mind food combining and healthy substitutions you can suggest. (E.g. soy or rice milk instead of cow’s milk)
Refer to the Nutritional Guidelines booklet. Keep in mind food combining and healthy substitutions you can suggest. (E.g. whole-grain bread instead of white)
Dinner:
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Daily filtered or spring water consumption (number of glasses/day): ________________
Any recurring food cravings (such as salt, starch, sugar, chocolate, etc.) please list asmany as applicable including time of day or month:
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FAMILY HISTORY
Please describe any relevant or major health related issues: (cancer, mental illness,diabetes, heart disease, etc.)
Mother: _________________________________________________________________
Father: __________________________________________________________________
Sister(s): ________________________________________________________________
Brother(s):_______________________________________________________________
Maternal Grandmother: ____________________________________________________
Maternal Grandfather: _____________________________________________________
Paternal Grandmother: _____________________________________________________
Paternal Grandfather: ______________________________________________________
Refer to the Nutritional Guidelines booklet. Keep in mind food combining and healthy substitutions you can suggest. (E.g. extra virgin olive oil instead of corn oil)
Explain the dangers of tap water and the importance of 8-10 glass per day of pure water
May indicate the presence of Candida, parasites, food allergies or sensitivites, as well as vitamin, mineral, and EFA deficiencies
This will shine a light on susceptibility to certain diseases and you may want to offer preventative measures. (E.g. regular exercise to prevent diabetes)
MEDICAL HISTORY
List all major health problems including any operations:
PROBLEM YEAR
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GENERAL HEALTH
Cardiovascular Skin Muscles/Joints
High blood pressure Boils Backache
Low blood pressure Bruises Broken bones
Pain in heart Dryness Limited mobility
Poor circulation Itching Arthritis
Swelling Varicose veins Bursitis
Stroke/murmur Skin eruptions Weakness
Respiratory Urinary/Kidney Gastro-Intestinal
Chest pain Excessive urination Belching
Difficulty breathing Water retention Colitis
Cough Burning urine Constipation
Tuberculosis Kidney stones Abdominal pain
Congestion Lower back pain Liver disorders
Itchy ears/eyes Wheezing Gallstones
Asthma Circles under eyes Ulcers
Coughing up blood Blood in urine Digestive troubles
This will help you in designing a nutrition, herb, and exercise program. Please note the limitations these might present (E.g. detoxification may be too drastic for someone suffering from a serious health condition.)
These will give you any indication as to which areas may need some extra support. Keep these in mind when suggesting herbal remedies (e.g. people with high blood pressure should not take licorice.)
Eyes, Ears, Nose and Throat
Ear aches Eye pains Failing vision
Hay fever Sinus infections Sinus congestion
Sore throat Tonsils Hearing loss
Canker sores Nosebleeds Difficulty breathing
General
Fatigue Night sweats Fever
Excessive thirst Loss of appetite Always hungry
Difficulty sleeping Irritability Cold hands and feet
Male Reproductive
Burning/discharge Lumps/swelling of testicles
Painful testicles Vasectomy
Female Reproductive
Age of first period: ___ Irregular cycles Pre-menopausal
Heavy bleeding Blood clots Menopause
Vaginal discharge Vaginal itching Pains/cramps
Painful intercourse Vaginal dryness Pelvic pain
Breast pain Breast lumps Anemia
Infertility Genital herpes Hot flashes
Mood Swings PMS Not able to conceive
Contraceptive/Pregnancy History
Oral contraceptives Rhythm-method I.U.D.
Diaphragm Condoms Mucous-method
Cervical Cap Spermicides Fertility lens
Please list each pregnancy you have had, including miscarriages:
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These will give you any indication as to which areas may need some extra support. Keep these in mind when suggesting herbal remedies (e.g. someone taking oral contraceptives will require additional nutrients, such as vitamin B6.)
CURRENT STATE OF EMOTIONS AND SPIRITUAL WELL-BEING
Please click all those that 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 and nervous for no good reason.
I don’t sleep well at night and have a hard time waking up in the morning.
I often suffer from bad dreams and nightmares.
There are many things I’d like to change in my life I just don’t have the means.
I have very low energy and often feel exhausted mentally and physically.
I don’t enjoy my work and would rather be doing something else.
I find my children irritating and 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 and 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 relaxation techniques.
I try to maintain peace of mind and tranquility.
I have many close friends that I can always count on.
I accept full responsibility for my actions.
I trust my intuition and 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 and 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.
If you see more clicks in the top part than at the bottom you’ll know that you are dealing with a more negative person and the treatment will entail extra effort on your part, including nurturing the soul, boosting self-confidence, releasing stress, learning relaxation, etc.
Please list approximate dates and describe the nature of any traumatic experiences youhave had in the past 7 years (divorce, surgery, end of a relationship, loss of job, change of residence, injury, death of a loved one, etc.)
YEAR EVENT
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LIFESTYLE HABITS
Do you engage in regular physical activity? Yes No
If yes, for how many minutes? _____________How often? __________________
Do you smoke tobacco? Yes No
If yes, how much? ________/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 in a week? ______________
Do you use artificial sweeteners? Yes No
Please use this space to add any other information about yourself that you think will be
helpful:
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Such events can greatly influence a person’s health and state of mind. Many diseases are brought on by emotional trauma and can best be treated by healing the underlying issues. Often just talking about these things can be helpful. Be a good listener and offer coping tools and support groups.
3-5 times per week for at least 30 minutes is recommended
Obviously consumption of these should be reduced or eliminated
TV can affect health and state of mind
Offer alternatives, discuss dangers (stevia, honey)
Herbalist’s Comments and Suggestions
Dietary Suggestions:
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Recommended Herbs and Nutrients including dosage:
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Use the Nutritional Guidelines booklet to offer general recommendations and substitutions based on the person’s diet. Emphasize the importance of optimum nutrition in relation to health. Discuss the importance of drinking adequate filtered or spring water. Talk about microwaves, artificial sweeteners, GE foods and other dangers the person may not be aware of. Emphasize the importance of eating organic foods as much as possible.
Use the Materia Medica booklet and the One Earth Herbal Sourcebook for reference. Keep in mind other nutrients or drugs the person may be taking and refer to the A-Z Guide to Drug-Herb-Vitamin Interactions in order to avoid harmful combinations. Don’t forget about: dosage, taken with food or without, length of treatment, things to avoid, etc. (A detoxification program is usually a good way to start off most people)
Lifestyle modification changes:
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Relaxation techniques and exercise:
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Other suggestions:
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This could include: tools to help quit smoking, eliminating exposure to chemicals (e.g. using natural cleaning products), cooking more meals at home instead of eating out, using natural skin care products, getting more fresh air, avoiding alcohol (except for the occasional glass of red wine), and any other things that would pertain to the person’s lifestyle habits.
Suggest tapes or classes for relaxation, Yoga, meditation. Emphasize the importance of exercise. Design a program to suit the person’s physical condition and lifestyle. Offer tools to reduce stress. Offer suggested reading materials.
This could include a referral to a massage therapist, reflexologist, chiropractor, etc. (It’s a good idea to set up a network with other natural health professionals). After filling out the questionnaire you’ll need to spend a great deal of time talking to the person and going through each point to enable you to offer very personal recommendations that could benefit his/her well-being, in addition to the general recommendations that everyone could benefit from.
