Name
*
First Name
Last Name
Email
*
Pronouns
Gender
Date of Birth
What drew you to seeking out herbal support?
What are your primary goals in working with an herbalist?
What other health related issues do you have/ have you had in the past?
Medications currently or previously used (over the counter and prescription). For each medication, please list: a) the medication, b) the dosage, c) how long, and d) reason for taking.
What is your monthly budget for herbs?
Please list any other practitioners you are currently working with (type of pracitioner and name)
Do any of these practitioners offer sliding scale?
Passions/ Interests / Hobbies
List any numbers, colors, songs, imagery, animals, fungi, stones and/or plants you are currently drawn to
Occupation
How long have you held this job?
Side hustle or creative endeavors that contribute financially?
How do you use your body at work?
Annual Income
Previous Occupations
Have you had any of the following?
Is there a blood family/ generational history of any of the above?
Other conditions
Are you allergic or sensitive to any substance (medications, pollens)?
Have you had any surgeries? If so, for what reasons? Please describe any complications:
Typical Bedtime
Typical hours asleep
Do you feel rested upon waking?
Do you have foods that you are allergic or sensitive to?
When you eat these foods what symptoms/ sensations do you experience?
Do you follow or have you ever followed a restricted diet? Which one(s)?
What food and/or flavors do you crave?
Supplements/Vitamins/Herbs currently or previously used
Please check any health issues you've had in the past or are currently experiencing
How often do you consume dairy?
Red meat
Fish
Chicken, turkey
Tobacco
Coffee
Vegetables
Fruit
Nuts and seeds
Alcohol
Soy products
Fried food
Water
Bakery goods and sweets
Chips/crackers
How many meals do you eat per day?
Snacks?
What is a typical day of food for you? Or, if there is not a typical day of food, what did you eat yesterday?
How would you rate your stress level as of late?
Do you have practices, tools, support systems, etc that you lean on in times of stress? If so, what helps?
Please list any major events in the last ten years of your life (or further back if it seems significant) and rough dates they occurred. Include events such as births, deaths, marriages, divorces, accidents, moves, job changes, illnesses and anything else you feel greatly impacted your life.
Is there anything else affecting your health right now that you would like me to know about?
What is bringing you joy as of late?