Health Consultation

Wellness Consultation

Enjoy a cup of tasty calming herbal tea while completing this form.
Full Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
What do you identify as your personal strengths?
YesNoNot Sure
If yes, please list past and present herbal supplements taken.
ie. Lemongrass tea, Elderberry gummy, etc
TeaCapsulePowderTincture/ExtractGummy
Instructions for symptom checklist

List your top three main physical discomforts and their approximate start date, in order of their importance:
Discomfort 1: What symptom do you feel? Where do you feel it in?*
Approximate Start Date of discomfort

MonthDayYear
Date
Rarely have symptomOccasionally have symptom (not severe)Occasionally have symptom (severe)Frequently have symptom (not severe)Frequently have symptom (severe)Not applicable
What triggers this discomfort? What makes it worse?*
Write further details for each of the marked symptoms in the section for 'explain'.
YesNo
If yes, then what brings relief?
ie. cold, heat, time of day, location, position, medication, etc
Discomfort 2: What symptom do you feel? Where do you feel it in?*
Approximate Start Date of discomfort

MonthDayYear
Date
Rarely have symptomOccasionally have symptom (not severe)Occasionally have symptom (severe)Frequently have symptom (not severe)Frequently have symptom (severe)Not applicable
What triggers this discomfort? What makes it worse?*
Write further details for each of the marked symptoms in the section for 'explain'.
YesNo
If yes, then what brings relief?
ie. cold, heat, time of day, location, position, medication, etc
Discomfort 3 - What symptom do you feel? Where do you feel it in?*
Approximate Start Date of discomfort

MonthDayYear
Date
Rarely have symptomOccasionally have symptom (not severe)Occasionally have symptom (severe)Frequently have symptom (not severe)Frequently have symptom (severe)Not applicable
What triggers this discomfort? What makes it worse?*
Write further details for each of the marked symptoms in the section for 'explain'.
YesNo
If yes, then what brings relief?
ie. cold, heat, time of day, location, position, medication, etc
High EnergyHyperactiveErraticRestlessLow EnergyExhausted EasilyFatiguedLethargicOther
Explain in more detail:
How do you feel upon waking?
Do you prefer more vigorous activities like running, etc., or gently activities like yoga, tai chi, etc.?
AngerMood SwingsIrritabilityAggresivenessAnxietyNervousnessFearDepressionDespondencyDissociatedOther
Explain in more detail:
Poor MemoryPoor ComprehensionPoor ConcentrationDifficulty Making DecisionsStutteringLearning DifficultiesPoor Physical CoordinationOther
Explain in more detail:
HeadachesFull FeelingDrowsinessHair LossDandruffThinning EyebrowsOther
Explain in more detail:
Chronic CoughingFrequent Sore ThroatHoarsenessMetallic TasteCanker SoreFrequently Clearing ThroatDry or Itching in MouthOther
Explain in more detail:
HeartburnConstipationStomach PainsStomach CrampsExecssive ThirstBloated FeelingNauseaDiarrheaBelchingGasRumbling NoisesLack of ThirstOther
Explain in more detail:
Do you crave a particular taste or food?
If so, what?
HypertensionHeart PalpitationsPounding HeartChest PainChest TightnessOther
Explain in more detail:
Chest CongestionShortness of BreathDifficulty BreathingHeavy BreathingOther
Explain in more detail:
Pain in JointsPain in MusclesStiffnessCrampingSpasmsOther
Explain in more detail:
WateryDrynessItchySwollen, or Sticky EyelidsDark Circles Under EyesBlurred VisionDark Floaters in the VisionLight Floaters in the VisionOther
Explain in more detail:
Itchy EarsEar AchesHigh Pitch Ringing in EarsLow Pitch Ringing in EarsOther
Explain in more detail:
Stuffy NoseDrippy NoseIrritatedDrynessSneezing AttacksBleedingOther
Explain in more detail:
AcneHives or RashDry SkinOilyHair LossFlushing or Feelings of HeatNumbnessItchingSwelling in Hands or FeetRaised BumpsOther
Explain in more detail:
Excessive SweatingFrequent UrinationUrgent UrinationUrinary IrritationOther
Constitution:
Height
Weight
Wrist Size
What size are your wrists
Temperature Preference
Which do you prefer?
Climate Preference
Which do you prefer?
Voice
Speaker Type
Are you a fast or slow speaker?
Cold Hands, Feet?
Gender
Ancestry
Any other constitutional descriptions:
Lifestyle: Please indicate typical food intake
Breakfast:
Lunch:
Dinner:
Snacks:
Daily Exercise:
Sleep Habits:
Nicotine/ Alcohol/ Caffeine Use:
Consumption of Liquids:
Anything else that was not listed on this form that you would like to share?
Thank you for taking the time to complete this form...

Go Herbs, provides health consultations and custom blended client herbal formulas as general support for health-related means.

Custom blended client herbal formulations are NOT intended to replace your primary care doctor's advice or medication management. Please consult with your physician.

Herbal blends and formulas are not included with your health consultation.

PRIVACY RULES - I FULLY UNDERSTAND that this form will not be shared or discussed.
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Wellness Consultation