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Earth Wisdom Botanica HERBAL CONSULT INITIAL INTAKE FORM

By signing below, I understand the herbal practitioner is not a licensed medical doctor and does not diagnose or prescribe. The herbalist will work with me to achieve my self-identified health goals. Their services do not take the place of a medical doctor. I take responsibility for the decisions I make regarding my health. 

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BEFORE YOUR CONSULTATION Please complete the form below prior to your consultation! Initial consultations range from anywhere between 1-2 hrs. In your consultation, your herbalist will get an in depth insight into your energetic constitution, including tongue and pulse diagnosis (no pulse if online appointment). After all information is gathered, your herbalist will compose an intricate wellness plan and herbal formula specifically crafted just for you, and only you! 

GETTING YOUR HERBS This formulation process is done post consultation, and may take 1-2 days to complete before you hear back with a finished product. Often times, extensive research and cross checking is involved to assure everything is in proper order and that all of your needs are met. Once your custom plan and formula is ready for pick up, you will be notified! Pick up/ meet up or delivery can also be arranged if needed! 

FOLLOW-UP Initial formulas are typically given for about two-three weeks time, and then a follow up appointment is scheduled to see how you are doing on your formula and if we need to change anything! 

PRICING Initial consultations are $100. Complimentary Ear Seeds and Magnets are included in the initial consultations. Follow up appointments are $50. Ear Seed and Magnets application is an additional $5 after first time free.  

What are Ear Seeds and Magnets? Auriculotherapy is a term used to describe the support and evaluation of pain, musculoskeletal disorders, and a broad range of issues by the application of seeds, magnets,or massage to specific locations on the ear.

Moxa:Stick on Moxa if applicable can be done in addition to initial and or follow up consultations or as a single Moxa consultation. Moxa application add on $10.

Reach out to learn more about Moxibustion.If interested in a Moxa only consultation- a different form will need to be filled out. 

What is Moxa? Moxibustion is the burning of Moxa (Ai Ye/Mugwort Artemisa Vulgaris or Argyi) alone or in combination with other herbs over or on acupuncture points to promote balance and health. It can be used for boosting the immune system, reduce pain, calm the mind,  aid with digestion and much more. 

(*These prices do not include cost of herbal formulas!! The herbalist does not take a profit from the herbs made. You will simply be paying for the ingredients). 

If pricing is keeping you from getting the help you need, sliding scale price range can be negotiated! Please please reach out if this is the case!

Tips accepted and appreciated in addition to the base prices of consultations <3

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e-signature and date please type below acknowledging above info^ *
DOB *
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AGE and Zodiac 
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Phone number & Email
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Emergency contact info(name, phone number)
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Main Complaint
Please describe your concerns and goals you would like help with:
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What do you typically eat? Do you follow a special diet?
Breakfast
Lunch 
Dinner 
Snacks 
Treats 
Please answer the above^
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ALLERGIES
Please list any allergies you may have
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Immuno Compromised: Y/N

Please list any auto-immune diagnosis 

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MEDS/ HERBS/ SUPPLEMENTS
currently taking & dose
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HEALTH HISTORY
Surgeries, Traumas of note, etc
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How much water do you drink daily? *
Do you drink coffee, tea, any other beverages daily? How much of each and when? *
cigarettes/drugs/alcohol
please list if you use these, and how much/often
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GASTROINTESTINAL

Please explain your digestion-How do you feel after eating: (tired/energized, bloated etc)

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Do you wake up at night to urinate? If so how often?
Any particular color to your urine? Other problems?
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Please list the numbers that apply to you:

1. Pain on urination 

2. Urgency to urinate 

3. Blood in urine

4. Sores on genitals 

5. Unable to hold urine 

6. Kidney stones

7. Frequent urination 

8. Belching

9. Constipation 

10. Nausea/Vomiting 

11. Black stools

12. Diarrhea

13. Hemorrhoids/Indigestion

14. Gas

15. Abdominal pain/cramps

16. Bad Breath/ Bad taste in mouth


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BM
how often and when?
Please see chart below and choose which applies and write the most accurate type in the box here:

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Please choose which applies:
SKIN AND HAIR
Please list hair or skin concerns (acne, rashes, hair loss etc)
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SLEEP
Please explain your sleep schedule and any issues etc
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STRESS
Please explain the effects of stress in your daily life, level of stress scale of 1-10 currently, and how you relieve it/ what makes it worse/better.
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Mood: Anxiety/Depression

Please explain if this effects you/ how your mood is currently

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Exercise/ENERGY
Please explain your daily activity for exercise/ movement. What is your job? 
Please explain your energy levels also
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REGENERATIVE PARTS 

People with Ovaries 

UTERINE Cycle length: Bleed length?

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Birth Control Y/N (which birth control do you use if Y) 

Are you pregnant now Y/N

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MUSCULOSKELETAL

Please list the numbers that apply to you:

1. Neck pain

2. Back pain 

3. Hip pain

4. Hand/wrist pains 

5. Areas of numbness

6. Shoulder pain

7. Foot/ankle pains

8. Muscle weakness 

9. Knee pain

Any other problems:

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HEAD, EYES, EARS, NOSE, THROAT

Please list the numbers that apply to you:

1. Recurrent sore throat 

2. Dry eyes 

3. Earaches

4. Sores on tongue/lips 

5. Eye pain 

6. Sinus problems

7. Dizziness 

8. Spots in front eyes 

9. Facial pain

10. Concussions

11. Cataracts

12. Jaw clicks

13. Poor vision/Night blindness

14. Change in taste

15. Grinding teeth

16. Headaches, Ear ringing, Hearing loss (where? when?

Any other head or neck problems:

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CARDIOVASCULAR AND RESPIRATORY

Please list the numbers that apply to you:

1. Dizziness

2. High blood pressure 

3. Fainting

4. Blood clots 

5. Difficulty in breathing 

6. Swelling of feet

7. Swelling of hands

8. Chest pain

9. Cold hands or feet

10. Irregular heartbeat 

11. Asthma

12. Coughing up blood 

13. Pain with breathing 

14. Pneumonia

15. Bronchitis

16. Excessive phlegm(list color)


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GENERAL

Please list the numbers that apply to you:

1. Poor appetite

2. Weight loss/gain

3. Fever 

4. Chills

5. Night sweats

6. Cravings

7. Changes in appetite

8. Thirst

9. Sweating easily 

10. Localized weakness

11. Poor Balance

12. Edema

13. Insomnia

14. Disturbed sleep 

15. Bleeding or bruising easily

16. Sudden energy drop (time of day )

17. Tremors

Other unusual or abnormal conditions you have noticed in your general sense of health:

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Please email any bloodwork to: Leaflygeeherbalist@gmail.com along with a photo of your tongue(only photo needed if this is a virtual consultation, in person consultation prior photo not necessary.) 

Please list anything else of note here! See you at your consultation! <3

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