Natalie Rader, Herbalist
natalie@motherofdandelions.com
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
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Phone Number
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Email
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DOB:
Age:
Weight:
Height:
Occupation:
Relationship Status:
Names ages of children:
What brings you here, and what are your hopes for working with me?
List any physicians, practitioners or healing modalities you are working with:
Physician's diagnosis and treatments, past and present:
List all known allergies:
Current medications (including over-the-counter):
Vitamins, minerals, herbs and supplements taken regularly:
List and date...
Any surgeries (including tonsillectomy, appendectomy, etc.):
Major injuries and accidents (falls, etc.):
Losses or traumatic experiences that may be affecting your health (deaths, divorce, etc.):
Significant or pertinent maternal, paternal or sibling medical history (chronic, genetic, serious diseases or causes of death, etc.):
Regular exercise or physical activity (type and frequency):
Are any immediate family members in a recovery program?
Do you run hot or cold?
Do you run damp or dry?
What is your average energy level on a scale of 0-10 (if 10 is high energy)?
Does it change throughout the day? If so, please describe:
How many hours do you sleep per night?
Do you wake up feeling rested?
Do you dream? If so, are there recurrent themes?
Do you experience anxiety? Please rate it on a scale of 0-10 (if 10 is high):
Diet:
Please Select
Vegan
Vegetarian
Omnivore
Do you follow a specific diet or protocol (ie. Keto, Paleo, fasting, etc.)? If so, please describe:
Please give an example of what you have for breakfast: What time?
Please give an example of what you have for lunch: What time?
Please give an example of what you have for dinner: What time?
Please list examples of snacks you eat: What time?
How often do you consume the following foods/substances?
Meat?
Never
0
1
2
Frequently
3
0 is Never, 3 is Frequently
Coffee/Caffeine?
Never
0
1
2
Frequently
3
0 is Never, 3 is Frequently
Fried Foods?
Never
0
1
2
Frequently
3
0 is Never, 3 is Frequently
Dairy?
Never
0
1
2
Frequently
3
0 is Never, 3 is Frequently
Soda/Diet Soda?
Never
0
1
2
Frequently
3
0 is Never, 3 is Frequently
Sugar?
Never
0
1
2
Frequently
3
0 is Never, 3 is Frequently
Gluten?
Never
0
1
2
Frequently
3
0 is Never, 3 is Frequently
Alcohol?
Never
0
1
2
Frequently
3
0 is Never, 3 is Frequently
Tobacco?
Never
0
1
2
Frequently
3
0 is Never, 3 is Frequently
Recreational Drugs?
Never
0
1
2
Frequently
3
0 is Never, 3 is Frequently
Water?
Never
0
1
2
Frequently
3
0 is Never, 3 is Frequently
Do you feel thirsty?
What foods/flavors do you crave?
Spirit
Do you feel generally content?
Do you have close friends and family?
Do you have a spiritual practice?
Do you feel your needs are being met?
Do you feel your life is being impacted by your current state of health?
Body Systems
Check all that apply
Describe your digestion and/or any digestive issues. Frequency and consistency of bowel movements? Gas? Bloating?
Cardiovascular/Circulatory
High Blood Pressure
Low Blood Pressure
High Cholesterol
Palpitations
High Triglycerides
Varicose/Spider Veins
Cold hands/feet
Poor circulation
Chest Pain
Stroke
Swelling in ankles and joints
IV Drugs
Heart Disease
Other
Describe Cardiovascular/Circulatory issues....
Respiratory
Allergies
Asthma
Sinusitis/Sinus infection
Post-nasal drip
Sore throat
Lung congestion
Difficulty breathing
Cough
TB History
Recurrent respiratory viruses
Snoring
Other
Describe Respiratory issues...
Skin
Acne
Boils
Bruise easily
Dandruff
Dry Skin/Scalp
Eczema
Fingernail ridges
Herpes
Itching
Psoriasis
Slow wound healing
Other
Describe Skin issues...
Eyes, Ears, Nose & Throat
Eye pain
Wet eyes
Dry eyes
Itchy eyes
Failing vision
Ear aches
Hearing loss
Tinnitus
Hay Fever
Tonsilitis/Adenoids
Itchy throat
Sore throat
Mucus
Other
Describe Eyes, Ears, Nose & Throat issues...
Oral
Cavitities
Root Canal
Sensitive Teeth
Bleeding gums
Receding gums
Mouth Ulcers
Dry Mouth
Gingivitis
Brush Daily
Floss
Other
Describe Oral issues...
Reproductive (male and female)
Fertility issues
Fertility treatments
Prostatitis
Urinary difficulties
Benign Prostatic Hyperplasia
Premature Ejaculation
Erectile Dysfunction
Low sperm count/motility
Fibroids
Cysts
Endometriosis
Vaginal infections
Painful intercourse
Cervical Dysplasia
Pelvic Inflammatory Disease
Anemia
Vaginal itching
Abnormal secretions
Other
Menstruation
Irregular menstrual cycles
Heavy bleeding
Painful cramps
Clots
Dark/Brown blood
Bright red blood
Bleeding between cycles
Mood swings
Other
Describe menstruation history and any other details....
Menopause
Hot Flashes
Vaginal Dryness
Mood Swings
Osteoporosis
Hormone Replacement
Sleep Disturbance
Sex Drive/Libido
Other
Describe menopause and date of last menses....
Contraception ? Date and type...
Sexually Transmitted Infections? Date and type...
Urinary
Incontinence
Painful urination
Cloudy urine
Lower back pain
Gout
UTI
Other
Describe Urinary issues...
Musculoskeletal
Arthritis
Back aches
Broken bones
Headaches
Mobility restrictions
Muscle tension
Sprains
Stiffness
Torn ligaments
Other
Describe Musculoskeletal issues...
Endocrine
Diabetes
Hypoglycemia
Pancreas
Pituitary
Sleep
Stress
Other
Describe Endocrine issues...
Lymphatic
Congestion
Infection
Mucus
Swollen lymph nodes
Other
Describe Lymphatic issues...
Immune
Autoimmune Disease
Chronic Fatigue Syndrome
Fibromyalgia
Neuralgia
Other
Describe Immune issues...
Describe any details of your own birth...
Other pertinent information
Is there anything else I should know?
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