Ask Rinzai

For assistance with what nutritional supplements & herbal formulas could be helpful for you, please fill out the following questionnaire.*

We tell everyone who comes to us in the Market that “You are your own living experiment”. We gladly support, encourage and educate. We look forward to hearing from you.

Your Name (required)

Your Email (required)

Phone

Height

Weight

Age

Do you consider yourself
 Underweight Overweight

How many pounds do you feel you are over/under weight?

Do you smoke?

If yes, how many cigarettes a day?

Do you drink coffee?
 yes no

If yes, how many cups a day?

Reason for Consultation or Goals?

Brief Health History (List major surgeries, diseases, injuries, etc.)

Day to Day Health Concerns?

Brief Family Health History?

If you are taking nutritional supplements, which ones?

List any conditions for which you are taking medication.

Describe your energy level:

Describe your sleep:
 Easy/Refreshing Insomnia Falling asleep sometimes difficult Falling asleep Deep sleep Light sleep Many Dreams Bad dreams

Describe your menstrual cycle:
e.g. last period, regular/irregular, how many days per cycle, painful

Menstrual Cycle Emotions?
 Depression Irritability Anger Sadness Crying

Sensitivity and/or Allergies? Describe:

Appetite and Digestion Issues? Describe:

Bowel movement: (constipation, diarrhea)? Describe:

Is your hair dry or falling out?
 Yes No

What kind of exercise do you do?

Daily Stress Level?
 Very High High Moderate Low None

General Enjoyment of Life?
 Excellent Good Fair Poor

Please feel free to expand on any concerns you think are important/relevant to your health:

If you could improve one thing related to your health, what would that be?

Calculate this to show that you are human:

The statements and products referred to throughout this site have not been evaluated by the FDA. They are not intended to diagnose, treat, cure or prevent any disease or condition. If you have a health condition or concern, consult a physician or your alternative health care provider. Always consult a medical doctor before modifying your diet, using any new product, drug, supplement, or doing new exercises.