First Name

Last Name

Phone *

Email *

Address

Street Address *

City

State

Country

Postal code

Birthday, including year

Pronouns *

She/Her

He/Him

They/Them

Other

Weight *

Height *

Eye Color *

Main reason/s for scheduling consultation (please include diagnoses, main complaints, and symptoms) *

Other known health issues you may have (whether you think they are related to reason for visit or not) *

Have you had any operations, injuries, car accidents, hospitalizations, or major illnesses in the past? Please list. *

Are you pregnant, think you could be in the next few months, or nursing a child? *

Yes

Maybe

Are you under a doctor's care for a condition? Which one(s)? *

Please list any and all practitioners you see regularly. (doctor, acupuncturist, chiropractor, massage therapist, etc.) *

Would you like me to be in touch with them regarding your health plan with me? *

Yes

Maybe, let's chat

Are you taking any prescriptions or over-the-counter drugs regularly (at least once a week)? Please list them and what you take them for. *

Tell me what supplements, if any, you are taking at least once a week. What do you take them for? *

Do you currently smoke tobacco, or have you in the last 7 years? *

Yes, currently smoke tobacco

No, never have smoked tobacco

No, used to smoke over 7 years ago

Yes, I do not currently smoke but quit within the last 7 years

Stress Management and Emotional Health

If cohabitation, is this a stressful relationship? Explain. *

Occupation & your relationship to it. (Do you like/love/hate what you do? Is this stressful? Does it bring joy?) *

Do you feel as if you are under stress? If so, where does it come from? *

Clarify Other (N/A if applicable) *

If you were to choose two of the above emotions which predominate your life, which ones would they be? *

Name something in life that you do that is really good for you. *

Name one thing you know you "should" be doing, but don't. *

What are your passions and interests? *

What do you do for fun? *

Please indicate approximate dates of and describe any traumatic experiences you have had in the last 10 years (divorce, death, illness or hospitalization, homelessness, unemployment, injury, etc.) *

If there's one thing in your life that you would like to change right now, what would it be? *

CAN you change it? *

Yes

Not Sure

Do you feel like you have superman/superwoman complex? Are you a workaholic? Do you feel like you have to do things yourself because no one else will do it as well? *

Are you a nervous, anxious, or "type A" personality? *

type A

What are the things that worry you the most? How often do you worry about them? *

Do you sleep well? *

Yes

Yes, with naps

No, falling asleep is hard

No, I wake and have a hard time falling back asleep

Do you nap? How many times a week? What's your tired time of day? *

Do you dream? Do you remember your dreams? *

Yes, dream regularly and remember them.

No, I do not dream or do not remember the dreams.

Sometimes!

Specify and/or explain your answers above. (If no boxes checked, just write N/A below.) *

Is it easy to wake in the morning? *

Yes, I jump up, bright-eyed and bushy-tailed!

No, I press snooze a lot.

It varies

Family History

Please describe any relevant or major health issues that you know of with your father. *

Please describe any relevant or major health issues that you know of with your mother. *

Please describe any relevant or major health issues that you know of with your grandparents (indicate paternal or maternal). *

Please describe any relevant or major health issues that you know of with any other family member worth mentioning. List recurrent family trends here. *

Food

How would you describe your relationship with food? *

Love/Hate

I love food and cooking

No interest. Food is merely fuel.

Describe a good day of eating, all meals and snacks, all beverages and water consumption. Walk me through it. *

Describe a bad day of eating and what that looks like. Do you eat "crap"? Do you skip meals and why? Do you hit the drive through? Walk me through it. *

How many days a week do you have good days versus bad days? (Be honest!) *

Name any food allergies and/or sensitivities. Tell me what kind of reaction you have to it as well. *

What's your energy level like? *

BadGood

If everything was good for you, what would you want to eat most? (What do you crave and potentially limit)? *

How much meat (red meat, pork, and poultry), in servings, do you eat per week? *

1-3

4-6

7-10

None, I am vegetarian or vegan.

How much seafood do you eat each week?

1-3

4-6

7-10

None, I am vegetarian or vegan

How many servings of dairy do you consume in a week (milk, cheese, yogurt, butter, etc.)

1-3

4-6

7-10

None, I am vegan.

How many servings of vegetables and greens do you get each DAY? *

Less than 2

3-5

6-8

9-12

How often do you eat fresh fruit (not canned)? *

once a day

twice a day

multiple times a day

Do you consume soda pop, alcohol, refined sugar, cookies, cakes, pastries, candy, or white bread often? How many times a day? *

once daily

multiple times a day

not daily, maybe 3-6 times a week

rarely, once a week or less

How often do you eat out? This includes food from cafés, drive throughs, sit-down restaurants, and take out. *

every day

2-3 times a week

4-6 times a week

Movement!

How often do you exercise/get movement that increases your heart rate? *

at least 30 minutes daily

more than 30 minutes daily

2-3 times a week, at least 30 minutes

4+ times a week, at least 30 minutes

List form and frequency of this exercise. (Running, Aqua aerobics, neighborhood walks, etc.) *

What's your favorite way to get movement and how often do you do it? *

Digestive System

Do you have food allergies or sensitivities? Please itemize. *

Elaborate on answers above or write N/A *

Respiratory System

Respiratory Clarification or write N/A

Circulatory System

Circulatory clarification or type N/A.

Urinary and Fluid System

Fluid Clarification or type N/A *

Endocrine System

Endocrine clarification or N/A *

Nervous System

Nervous system clarifications or N/A *

Structural System

Clarify Structural answers or N/A

Please add any additional information that would be helpful. Write N/A if it has been covered. *

Statement of Understanding

The human body has the innate power to heal itself. Without this power to self-heal, even the most advanced medications and surgical procedures would ultimately fail. The role of the herbalist in this healing process is to consider the client as a whole person and to consult with the client concerning changes in lifestyle, diet, and supplementation of herbs and/or vitamins to foster an increased state of balance and health, thus maximizing the body's self-healing capabilities.

I practice nutrition and lifestyle related assessment, diagnosis, and therapeutic methods based on the body's own healing system. This scope of practice includes dietary assessment, dietary changes, physical diagnosis related to nutrition (including pulse, palpation, tongue, and observation), interpretation of laboratory values relating to nutrition, dietary counseling, reviewing medical records, recommending diet therapies, recommending nutritional and herbal supplements when indicated, and identifying proper treatment strategies- all with the goal of achieving a healthy homeostasis.

My approach is to combine numerous alternative healing methods together with the latest scientific findings and clinical practices. Nutrition, lifestyle, and herbs are my primary specialty and represent my area of expertise. The degree of incorporation of these systems will vary from case to case. The basic principle is to help the body’s natural capacity to restore balance, health, and harmony. Assessments are focused on identifying patterns and imbalances. Depending on the patient’s wishes, recommendations may incorporate nutrition, herbs, supplements, counseling, exercises and lifestyle. Recommendations may be use to instill physical, emotional, mental, and/or spiritual balance.

I am NOT a Medical Doctor nor do I practice western medical assessment, diagnosis, or treatment. I do not claim to cure disease. Nor do I give advice about pharmaceuticals and medications at any time. I have no objections to my clients being seen or evaluated by their own medical doctor. If you have any questions or concerns about your condition, I highly recommend you discuss it with your physician. I am willing to work as part of a health care team including physicians and other health care providers and often do. If you would like me to work with your physician, please inform your physician also of this wish. I also recommend you inquire and explore any recommendations I provide with any professionals in health care.

Further, I create customized herbal formulas to fit the exact profile for what I feel clients need. Clients are not obligated to buy any products. I encourage clients to buy any supplements wherever it is most convenient for them, and I also make and sell many herbal products and some food products for a profit. I dispense them directly as a convenience and to ensure patients are receiving the specific, individualized herbal formula they need. I use mostly regional herbs that can be grown and/or wildcrafted in my area.

The recommended nutritional/herbal supplements are not a replacement for the medications prescribed by your medical doctor.

Due to HIPPA privacy regulations, your information will be held confidential and not shared with anyone unless you specify in writing who you want me to share with.

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