Take Care Herbals Intake Form
I look forward to working with you! Thanks for taking the time to fill out this form. Please know-this information is confidential. Feel free to not fill out any information that you feel uncomfortable with answering.
Email address *
Name *
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Contact Information: Please include your address and phone #.
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How did you hear about Take Care Herbals?
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Is this consult in person or distance? If not in person, do you prefer skype, zoom, facetime, or phone?
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What is your gender? What pronouns do you use?
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What do you do for work?
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What do you like to do for fun/enjoyment outside of work?
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What's your birthday? Include your astrological signs if it's fun for you!
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What Brings You Here Today?
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Please describe your symptoms, physical and/or emotional. Include how long you have been experiencing these symptoms.
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What are your current health concerns?
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What kind of support are you looking for today (ex. herbal medicines, dietary recommendations, referrals, information, etc)?
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Are you currently being or have you been treated for this already? Please explain, including the outcome if treatment has stopped.
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Who are your health care providers? List all you think appropriate: MD, acupuncturist, chiropractor, etc. Please include phone # and/or email if possible.
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When was your last physician visit?
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When was your last gynecological exam?
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Please list any diagnosed medical conditions.
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Please list any surgeries you have had, with approximate date.
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Please list any traumas with date (if you feel comfortable and it feels important to mention in our work). I.e. Car accident w/ head trauma-2015
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What medications are you currently taking? Please include prescriptions, over-the-counter drugs,herbs, and vitamin supplements. This information is strictly confidential, but is extremely necessary for us to be able to provide you with appropriate care.
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All pharmaceutical and /or recreational drugs that you have taken for extended periods of time in the past, including the length of time you took them. This information is strictly confidential, but is extremely necessary for us to be able to provide you with appropriate care.
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Have you ever experienced an adverse effect to a drug? To an herb or herbal medicine?
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Please list ALL known allergies (foods, medications, hay fever, etc.)
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What kind of stresses are you under? How do they affect you?
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Please list any relevant family history.
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Do you smoke? If so, how much per day/week?
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Do you drink coffee? If so, how much per day/week?
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Do you drink alcohol? If so, how much per day/week?
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Do you drink soda? If so, how much per day/week?
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How much water do you drink daily?
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Are you now or have you ever been vegetarian or vegan? If so, how long?
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Please describe your typical breakfast?
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Please describe your typical lunch?
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Please describe your typical dinner?
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Please describe your typical snacks?
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What are your favorite foods?!
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Do you have any favorite herbs that you use in cooking,tea, tincture, powder, other form?
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Do you have any food allergies/intolerances?
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What kind of exercise do you get? i.e. walking the dog, going to the gym, etc.
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How many hours of sleep do you get a night?
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Do you wake up well rested?
Are you typically sleepy or fatigued the next day?
Please describe your bowel movements (frequency, regularity, color, times of day, stool consistency)
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Gastrointestinal Health: Please check any boxes that you are currently experiencing.
Have you had any of the above conditions in the past? Please elaborate?
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Urinary Health: Please check any boxes that you are currently experiencing.
Have you had any of the above conditions in the past? Please elaborate?
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Cardiovascular: Please check any boxes that you are currently experiencing.
Have you had any of the above conditions in the past? Please elaborate?
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Muscles, Joints, Nerves: Please check any boxes that you are currently experiencing.
Head and Sensory Organs: Please check any boxes that you are currently experiencing.
Have you had any of the above conditions in the past? Please elaborate?
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Respiratory: Please check any boxes that you are currently experiencing.
Have you had any of the above conditions in the past? Please elaborate?
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Skin: Please check any boxes that you are currently experiencing.
Have you had any of the above conditions in the past? Please elaborate?
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Generative Health: Please check any boxes that you are currently experiencing.
Have you had any of the above conditions in the past? Please elaborate?
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Have you had an abnormal pap? Please describe.
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What was the date of your last menstrual cycle (if applicable)
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Please check any boxes that you are currently experiencing.
Have you had any of the above conditions in the past? Please elaborate?
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Do you have an autoimmune condition/s? If so, please describe.
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Do you experience unusual or persistent fatigue? If so, please describe?
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29. Anything else I didn’t ask that you would like to include?
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Vitamin and Mineral Deficiencies Symptom Checklist: Please check all that apply. Some of these you may have checked above-please check here as well.
Please describe any health goals you have for working together.
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