Practicing Community Herbalist
Perianth Herbs Inc.
•HERBAL CONSULTATIONS, THERAPY & REMEDIES•
All medicines grown or gathered personally and/or ordered from reputable sources.
Privacy: Please be assured that everything submitted on this intake form and shared during any consultation is completely confidential between the client and the practitioner.
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Please list all physicians and other healthcare providers or consultants (such as Acupuncturist, massage therapist, etc) you see on a regular basis:
Family Medical History:
Please describe any relevant or major health-related issues:
Present Health Status:
Check each item where symptoms apply and elaborate in space provided below if necessary.
Eyes, Ears, Nose, Throat and Gastro-Intestinal
Common Physical Activities
Please check each item listed below if it is included in your daily - or usual - diet.
Mark if Daily, Weekly, Monthly or Never
Describe below your typical meals. Please be as specific as possible. For example, Instead of "oil" list type of oil, such as olive, corn, etc. Instead of "bread" list whether white or whole grain, etc. Instead of "vegetables" list type of vegetable, how prepared, canned, frozen, or fresh, etc. Please include beverages, type and quantity (two cups of coffee, one glass of orange juice, etc.)
What’s a good day of eating like?
What’s a bad day of eating like (meals on the run, etc)?
Current State of Emotions and Feelings
Please take a moment to answer the following questions:
If you were to choose two Emotions which seem predominant in your life, they would be...
Supplements and Medications
Do you use any other drugs?
Have you used any drugs in the past?