Ask Rinzai

If you would like more in depth assistance with how to take care of yourself we invite you to fill out the following questionnaire and email it to us. We will then make specific supplement recommendations unique to your situation.*
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.

Last Name	First Name
Email	Phone
Height Weight Age Sex
Do you consider yourself Underweight Overweight
How many pounds do you feel you are over/under weight?
Do you smoke? *Yes No
*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? (e.g. tired, lower back pain, allergies, headaches, joint pain, stuffed nose, difficulty sleeping, etc.) List things that you have just gotten used to or that happen to you more often than you like.

Brief Family Health History?

How many times per year do you get a cold or flu?
Diet (summarize how you eat and list any special diet such as high protein, raw food, etc.)

Are you taking any nutritional supplements? *Yes No
*If yes, please list the supplements you take.

List any conditions for which you are taking medication.

Emotional Tendencies?
Depression Sadness Panic Attacks
Worries Overly Excited Sensitive
Anxiety Aggravated Angry
Describe:

Energy Level?
Low Up and Down Exhausted
Hyperactive Nervous Energy Abundant
Describe:

Sleep Patterns?
Easy/Refreshing Insomnia
Falling Asleep?
Sometimes Difficult Always Difficult
Sometimes Very Difficult Always Very Difficult
Sleepy in Daytime Take Naps
Waking Up?
Times per night you wake up too early?
Times per night you wake up and cannot fall back asleep?
Describe:

Sleep Quality?
Deep Light Bad Many Dreams Bad Dreams
Grinding Teeth Talking in Sleep
Describe Other Sleep Patterns if any:
Menstrual Cycle?
Date of last period: Regular Irregular
How many days per cycle? How many days did it last?
Were there clots? Yes No
Menstrual Pain? Yes No
Menstrual Cycle Emotions?
Depression Irritability Anger Sadness Crying
Other Menstrual Cycle Emotions? Describe:

Sensitivity and/or Allergy? Yes No
Noise Airborn Particles Food Drugs
Other Sensitivities/Allergies? Describe:

Appetite and Digestion? Normal Abnormal
Rapid Hungering Poor Appetite Nausea Bloating
Gas Anorexia Hungry, but no desire to eat.
Other Appetite and Digestion Issues? Describe:

Bowel Movement? Once a day Twice a day Less often
Constipation Diarrhea Loose Watery
Describe:

Water drinking? Normal Abnormal
Thirsty Dry Mouth Drink a lot
Describe:

Are your nails weak or brittle? Yes No
Is your hair dry or falling out? Yes No
How many times per day do you eat?
Do you overeat? *Yes No
*If yes, which foods and how often do you overeat?
Describe:

Do you get noticeably irritable, lightheaded, or weak if you have not eaten in a while? Yes No
Please list any food aversions and/or foods you dislike:

Do you crave any of the following frequently?
Sweets/Desserts Chocolate Diet Sodas Bread/Pasta
Meat Fish Milk or Cheese Fried Foods
Peanuts Alcoholic Drinks Other
Describe:

Please check off any of the following that pertain to you (recent past or present):
Acne/Blemishes Addiction (alcohol/drugs) Anemia
Anorexia Anxiety or Nervousness Arthritis (Rheumatoid or Osteo)
Bladder Infections (Cystitis) Bloating, Gas or Indigestion
Blood Sugar Problems Cancer Colds or Flu (frequent)
Cold Sores Chronic Fatigue Constipation Dandruff
Depression Diabetes I (insulin dependent)
Diabetes II (adult onset) Diarrhea Difficulty Losing Weight
Difficulty Gaining Weight Emotional Problems (instability or sensitivity)
Emphsyema Fainting Gall Bladder Problems Gout
Hair Loss or Poor Hair Growth Headaches Heartburn
Heart Disease or Problems Hemorrhoids
Herpes Type I (mouth/face) Herpes Type II (genital)
High Blood Pressure High Cholesterol HIV Hot Flashes
Hypoglycemia Insomnia Intestinal Problems
Kidney Stones Liver Problems Loose Stools
Memory Loss or Confusion Menopausal Symptoms
Nails-Poor Growth Nails-Whte Spots Panic Attacks
Parasites Pregnant or Nursing Mother Respiratory Problems
Ringing in Ears Seizures Severe Mood Swings
Skin Conditions Stroke Suicidal Tendencies
Thyroid Condition Ulcer Yeast Infections Other
Describe:

Women: Please check any that pertain:
PMS Irregular Periods Painful Menstrual Cramps
Birth Control Pills Low or Decreased Libido Menopause
Painful Intercourse Hysterectomy Fertility Concerns
Men: Please check any that pertain:
Frequent Urination Difficulty Urinating Difficulty with Erection
Low or Decreased Libido Prostate Enlargement
Do you exercise? Yes No
What kind of exercise?
How often? Since when?
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?

Rinzai's Market
Call 866.804.2185
2081 W. State Route 89A #5
Sedona, AZ 86336
info@rinzaismarket.com

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