Free Herbal Consultation Intake Form- Water Daughter Apothecary
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Please fill out this form to the best of your ability- it will take about 20-30 minutes to complete.
This form and the contents of will be kept confidential and you will receive a copy after you complete it. This form will never be shared with anyone unless you provide written consent. Your personal information will remain confidential under this written privacy agreement. 

 Herbal suggestions will be made based on your answers. There are many herbs contra-indicated for pregnancy, breastfeeding, and with certain medications. Your honesty helps shape all recommendations. We have a collection of herbs in the donation-based apothecary, but there may be instances that we will recommend herbs outside of our repertoire. All recommendations made will be brands and quality that we really believe in. Some of those brands include: Gaia Herbs, Herb Pharm, Ancient Nutrition, Garden Of Life, Natura Sophia, Herbalist & Alchemist, Nature's Path. 

 This form is only for people 18 and above- If you are a minor please have a parent or guardian fill out this form. 

This form is intended to make herbal suggestions based on your condition or current concerns. This form is not intended to treat, diagnose or cure any illness. Claims and statements about the herbs and extracts I use/make have not been evaluated by the Food and Drug Administration. 

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Email *
Client Name *
Date of Birth *
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DD
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Where do you live?
Phone number: (with area code) *
Gender and pronouns
Describe your primary health concerns that you are currently experiencing. How long have you been having this experience or these symptoms? *

What was going on in your life in the months preceding this condition?

Do you have a medical diagnosis? Please include any significant lab results you're aware of or info.

 *
If you have a medical diagnosis above, please include your Doctor's prescribed treatment or treatment plan. Please include prescriptions (name, dose, frequency) and any other relevant info. 
Family Health History: Any known conditions in your family that you'd like us to be aware of? Ex. Heart disease, auto-immune, diabetes *

Current or recent prescription medications, supplements, natural remedies and/or over the counter medications (. laxatives, pain relievers, antacids, etc .; Include dosage )

Current or Recent Health Care Practitioners

What other health related issues have you had in the past? Please describe symptoms and relative dates

Please list any previous medications and treatments you've had in the past

Please list any operations you have had and the date

Please list any major injuries/accidents, including date

 *

Please list any traumatic experiences not treated medically 

( divorce , loss of job, death of loved one, etc) 

Have you had unusual reactions to any drugs or herbs?

 *

Do you have any allergies, sensitivities, or ongoing infections

 *

What behaviors or habits do you engage in regularly that you believe support your health?


What behaviors or habits do you engage in regularly that you believe are not good for you or that you want to change?

Please describe any current or past use of addictive or recreational substances: 

 *
What kind of exercise do you get on a regular basis?
 *

How stressed do you feel on a scale from 1 to 7, 

1 being no stress

7 being the most stressed you've ever felt. 

 *

What are the major sources of stress for you and how do you respond to these stressors?

(example: Work is a source of stress for me. When I'm stress, I respond with feeling anxious. I also tend to get sick when I'm stressed.)

How are your energy levels in general?

Do you have any difficulty falling asleep?

 *

Is it hard staying asleep?

What time do you go to bed and  time do you wake up? 

 *

Do you feel rested?

 *
Do you dream?
 *

If you wake in the middle of the night, how often do you wake?

What times of night do you wake? 

What wakes you? 

Do you run hot or cold? 

What parts of your body feel the hottest/coldest? 

What is your favorite temperature/ climate? 

What part of the day are you warmest and coldest?

(if you're not sure, skip these questions.)

How would you rate your appetite?

1 being rarely hungry

7 being so often hungry you're ravenous

 *
Tell us about your diet: What do you usually eat? How many meals do you eat a day? 
Do you have access to food on a regular basis? Can you afford to feed yourself?
Do you ever experience any of these digestive issues? *
Required
Do you have regular bowel movements?  *
Would you say your bowel movements are....
Urinary Issues?
Respiratory Issues?
Cardiovascular?
Immune / Lymphatic?
Skin?
Musculoskeletal?
Ears, nose, throat?
Nervous system? *
Required
If you get headaches, can you describe the pain, location & triggers?
Which emotions do you experience most frequently?
Endocrine/Metabolism
Anything this form did not address that we should know?
I want my follow up contact to be by *
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