Category Archives: Uncategorized

Test Intake

    Carla Martinez
    Practicing Community Herbalist

    Perianth Herbs Inc.

    •HERBAL CONSULTATIONS, THERAPY & REMEDIES•
    All medicines grown or gathered personally and/or ordered from reputable sources.
    perianthherbs@yahoo.com

    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.

    * indicates a required field.

    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.

    Cardiovascular Skin

    Muscles/Joints Respiratory

    Eyes, Ears, Nose, Throat and Gastro-Intestinal

    Sleeping Patterns

    Urinary/Kidney

    Miscellaneous

    Common Physical Activities

    Dietary Information
    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?