The Spring Within
Cici Cyr, community and clinical herbalist
206-384-8681
Herbal Consult Intake Form
(please complete and email back at least two days before consultation)
Personal Information
Name Preferred Name
Gender Pronouns Date of Birth
Emergency Contact
Name Phone
Relationship to Self
Allergies (medications, foods, environment, etc.)
Current and Past Medical Issues (chronic conditions, acute conditions, surgeries, illnesses of note)
Current Medications, Supplements, and Herbs
Name Dosage/Frequency Reason
Please list any relevant lifestyle information you’d like to include (related to food, exercise, home life, emotional life, etc.
Stress
Please list primary sources of stress in your life
Do you have tools and techniques you use for stress relief?
Sleep
Approximate hours of sleep per night?
Do you feel well rested when you wake up?
Do you sleep through the night?
Is there anything else related to sleep you’d like to include?
Primary Health Concerns (what’s bothering you and what would you like to address?)
Primary Health Goals (please include up to three main goals to address in consultation)
Preferred form of taking herbs? (please circle Yes or No)
-Incorporate into food? Yes/No
-Take them in tea? Yes/No
-Take a tincture? Yes/No
-Would you prefer a remedy without alcohol? Yes/No
-Okay with taking capsules? Yes/No
-Is taste important to you? Yes/No
-Do you grow your own? Yes/No
-Would you like to make your own remedies? Yes/No
-Is cost important? Are you working within a budget? Yes/No
Is there anything else you’d like to include that wasn’t covered above?
Thanks and see you soon!