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Build Your Own Apothecary Questionnaire
To better serve you, I’ve prepared this intake questionnaire to get to know a little bit more about what you might be needing in your own Apothecary.
[Each of these kits comes with a labeled Ammo box, Materia Medica, Copper Talisman & Symbolism witte up.]
Imagine we are on The Mountain together and we're having a conversation about your needs around Building Your Own Apothecary. I'm looking to understand what sorts of things you might be needing Allies for. Where you have problems or issues in your body, mind, emotions & spirit. For the things you already "Know” you Want, you'll find a section that you can fill in for that.
Please also share what Medicines you have On-Hand, so I don’t consider things you are already stocked with!
I'll also be asking you what kind of price range you're working with. That way I can suggest the best range of items to fit within your budget.
Please fill this out to the best of your ability and then we'll have another conversation either via text or voice, I'll share my thoughts from your selections, together we can make a plan and go from there!
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By checking the box below you understand that I am not prescribing or diagnosing. Any Herbal Dietary Supplements you choose to purchase are based from an Educational & Clinical perspective. Also checking this released Raine Ford of Mountain Woman Medicine and Nemeton of liability from effects of said Herbal Dietary Supplements.
Yes I Understand.
No. (By checking this you understand I am not available to work with you.)
Are there any herbs in specifics that you KNOW you Want??
What Herbs do you already have On-Hand and in what form (dried, tincture, oil, ect)
Select the following systems that you are looking to support.
Upper Respiratory System (Sinuses, Throat)
Lower Respiratory System (Lungs)
Integumentary system (Skin)
Nervous System (Anxiety, over stimulation, Nervines)
Women's Moon Time
Muscular skeletal & Joints
General First Aid
Other. I’d rather explain.
Select the following Types of Medicines that you might be interested in.
Tincture Formulas (Combinations of Herbs extracted with Alcohol & water)
Tincture Simples (Single Herbs extracted in alcohol & water)
Teas (Loose Blend of Dried Plants)
Dried Herbs (Individual Dried Plants)
Lozenges (Dried herbs packed with honey & some resin/tinctures (no alochol)
Herbal Candies (Made with Sugar)
Liniments (Muscle & Joint Topical)
Washes (Skin treatments: Burns, Bug bits, Itch Wash, ect)
What price range are you looking to work in?
$250 - $400
$400 - $600
$600 - $1,000
I don’t need to stay within a budget.
Monthly Instalments (3 medicines @ $55 / month)
Monthly Payment Plants (Part down, monthly payments till its paid)
I have a specific amount I can spend, please note below.
I may need more then 1 box or 1 for someone else.
What Pharmaceutical Medications or Herbal Supplements Do you take everyday?
What known allergies do you have? (Medications, plants, insects)
Are you pregnant or trying to get pregnant?
What kinds of things would you share with me, about where you are & what you need? (Feel free to write as much as you need here)!! <3
If you had to put a priority to what you have shared, what would you most like to support?
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