New Client Intake
Mark Tulk, Clinical Herbalist. Alfred, NY.
Personal details
All details submitted will remain confidential.
Patient Name *
Parent/Guardian Name (if relevant)
Address *
Telephone *
Email *
What is your gender? (or pronoun preference)
What is your date of birth?
MM
/
DD
/
YYYY
What is your height in feet and inches?
What is your current weight in pounds?
Work/Study
What is your current occupation?
How many hours to you typically work/study each week?
Symptoms/Diagnosis
How would you rate (out of 10) your overall health, vitality, energy levels?
Poor Health
Good Health
Clear selection
Primary complaint (what is the main reason for contacting me?)
Please describe all major symptoms (please be as specific and detailed as possible)
How long have you experienced these symptoms (weeks, months, years?)
How would you rate your current level of discomfort/pain?
Least
Greatest
Clear selection
Has there been a diagnosis by another practitioner?
Clear selection
If YES to the above, by whom and what was the diagnosis?
What protocols (if any) have already been tried for the presenting problem?
Do you have any lab test results relating to this condition? If so, please summarize below.
Medical History
Only detail your medical history as it relates to your current condition/complaint.
Do you have any history of hospitalization or surgery?
Have you ever been diagnosed with liver or kidney disease?
Do you have any history of high cholesterol or blood pressure?
Do you have any history of gastrointestinal problems?
Any allergies or sensitivities (food/medicine)?
Lifestyle
Please try to be as honest as possible when answering the following questions.
Caffeine intake?
Sugar intake?
Alcohol intake?
Tobacco Use?
Exercise habits?
Sleep patterns?
Diet: What foods do you typically eat? Please give examples of normal breakfast, lunch and dinners.
Medication
Are you currently taking any prescription medications? (names, dosage, frequency and purpose of each)
Are you currently taking any herbs or supplements? (names, dosage, frequency and purpose of each)
Are you a medical cannabis user? (Please explain)
(Women) Are you currently pregnant or trying to conceive?
Do you have any other health issues, or other matters you would like to discuss?
How did you find out about Mark Tulk/Herbal Wisdom?
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