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for Lily Kunning, Community Herbalist
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Email *
Full Legal Name (and name you prefer to be called in parenthesis) *
Phone number *
Mailing Address *
Birthday (including year) *
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Sex/Gender/Pronouns *
Weight *
Height *
Eye Color *
Main reason/s for scheduling consultation (please include diagnoses, main complaints, and symptoms) *
Other known health issues you may have (whether you think they are related to reason for visit or not) *
Have you had any operations, injuries, car accidents, hospitalizations, or major illnesses in the past? Please list. *
Are you pregnant, think you could be in the next few months, or nursing a child? *
Are you under a doctor's care for a condition? Which one(s)? *
Please list any and all practitioners you see regularly. (doctor, acupuncturist, chiropractor, massage therapist, etc.) *
Would you like me to be in touch with them regarding your health plan with me? *
Are you taking any prescriptions or over-the-counter drugs regularly (at least once a week)? Please list them and what you take them for. *
Check any boxes where you have a diagnosis from a physician. *
Required
Specify and/or explain your answers above. (If no boxes checked, just write N/A below.) *
Do you currently smoke tobacco, or have you in the last 7 years? *
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