Custom Tea Blend & Wellness Intake Form
Please complete the questionnaire. *Note: I am neither an MD nor ND. I do not have the years of medical schooling that it takes to safely and properly give a diagnosis, and although I am knowledgeable about holistic remedies, anything I suggest is in no way a cure. I cannot predict how a remedy will work for you, every body is so uniquely different. Always refer to your medical care provider for questions about your health. The information I provide is not intended to be a substitute for medical treatment but instead to help support or bolster what concerns arise. Please consult your medical care provider before using herbal medicine, particularly if you have a known medical condition or if you are pregnant or nursing. You are responsible for your own health. As with conventional medicine, herbal medicine is vast and complex, and must be used responsibly. Some herbs are contraindicated with certain pharmaceutical drugs.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Contact Number
*
Date of Birth:
*
-
Month
-
Day
Year
Date
What is your age?
What is your gender?
*
Please Select
Male
Female
N/A
How many kids do you have?
How many pets do you have?
Have you ever been diagnosed with any of the conditions listed here?
*
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Seizures
Thyroid disease
Hepatitis
Other
None
If any of the prior conditions apply, who made the diagnosis (i.e. M.D. naturopath, clinical herbalist, etc). When was the diagnosis made?
Please note any other health issues/concerns that you have had in the past or are currently experiencing.
List all medications you have used in the past 6 months including medications currently being taken (be sure to include prescription drugs, over-the-counter medications you have purchased yourself, herbs, vitamins and supplements.)
*
List any allergies/sensitivities (including food, drugs, chemicals, pets, seasonal, latex, etc.):
*
Constitution
Pick the most accurate option with the most relevant descriptors of your overall health and wellbeing. Choose the option that contains a description that resonates with your experience, even if not all words within that option feel entirely accurate. If multiple options seem applicable to you, think about which traits or behaviors have been the most dominant or defining throughout the entirety of your life. If two options feel equally accurate choose those two. Rarely will all three feel equally accurate, but if they do, choose all three.
Skin
dry, rough, cold, thin
soft, warm, fair, moles and freckles, flushes easily
oily, thick, cool, pale
Hair
dry, rough, brittle, curly or kinky, coarse
thin, fine, straight, early gray, balding
thick, oily, wavy
Teeth
irregular, protruding, crooked, thin gums, tendency to tooth decay
regular, moderate, soft gums, yellowish
big, white, strong, healthy
Joints
dry, cracking, cold, bony
moderate
well lubricated, large, not visible
Musculature
slight and stiff, tendony
medium, flexible
firm, stout
Appetite
variable, scanty, can miss a meal without noticing it
good, excessive, gets hangry (hungry + angry) if a meal is missed
low but steady
Thirst
variable
excessive
steady
Sweating
variable to none
excessive, odorous
moderate to none, no odor
Sleep
wakes easily, difficult to fall asleep
falls asleep easily, stays asleep, has difficulty sleeping in warm weather
sleeps long and deep, has difficulty waking up
Elimination
irregular, dry, hard, tends to constipation
regular, loose, soft, tends to diarrhea
slow, regular, oily
Dreams
often fearful, flying, running, jumping, dancing
often fiery, passionate, angry, violent
often calm, romantic, watery, of relationships
Emotions
unpredictable, anxious, insecure
irritable, jealous, blaming, judgemental, angry, critical
calm, quiet, loving
Mind
restless, active
aggressive, intelligent, intense
calm
Weather
struggles in cold, windy weather
struggles in hot weather
struggles in cold, damp weather
Reaction to Stress
stresses easily, struggles with staying grounded
rises to the challenge
rarely gets stressed; plods along
Personalized Blend
Answer the following questions related to what you would like from your custom blend.
I want this blend to focus on (choose 1-3):
*
Adrenals
Allergy/Sinus
Balancing hormones (male or female)
Breastfeeding support
Cardiovascular system
Digestion
Energy
Fertility
Focus
Grief support
Immune system
Kidneys
Liver
Menopause support
Menstrual health
Mood regulation
Physical performance and recovery
Postpartum support
Prostate health
Respiratory system
Sleep
Skin conditions (i.e. acne)
Urinary tract
Describe in more detail the options you chose above.
*
Do you want this blend in the form of loose leaf tea or as capsules?
*
Loose leaf tea
Capsules (for an additional charge)
Lifestyle
Answer the following questions related to your lifestyle.
What are your hobbies/passions?
Are you able to move your body each day? (i.e. gym, dance, walk, yoga, chasing after kids, etc.)
Do you smoke cigarettes/vape? If so, how often?
How much caffeine do you consume per day? How do you get your caffeine (coffee, green tea, energy drinks, etc.)?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Women: General Reproductive Health
Describe your menstrual cycle: (how long is your cycle, how long does your bleed last, do you regularly keep track of your cycle? etc.)
Are you currently pregnant?
Are you currently breastfeeding?
Are you currently using hormonal birth control? If so, what kind?
Are you perimenopausal/menopausal? When did that start for you?
Herbal Taste Preferences
Please rate your preferences on the following herbal flavors/tastes. (1 being complete dislike, 5 being it's a favorite flavor)
Licorice
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Toleration of spicy flavors (i.e. cayenne, chili peppers, etc.)
No spice
1
2
3
4
Super spicy
5
1 is No spice, 5 is Super spicy
Cinnamon
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Ginger
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Citrus
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Lavender
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Mint
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Are there any other flavor preferences or aversions that you would like me to know about?
Is there anything else you would like me to know?
Submit
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