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Client Intake Form
Welcome to The Herb Doctor!
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1
Name
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This field is required.
Who are you?
First Name
Last Name
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2
Gender
*
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There's only two to choose from. So take your pick.
Please Select
Male
Female
Please Select
Please Select
Male
Female
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3
Birthday
*
This field is required.
When is your special day?
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Birthday
Month
Day
Year
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4
Height (inches)
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I bet you're taller than me!
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5
Weight (lbs)
*
This field is required.
For dosing purposes.
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6
E-Mail
*
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How can I reach you?
example@example.com
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7
Country
*
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Where are you from?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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8
What do you do for work?
*
This field is required.
If you don't work, put NA.
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9
Reason for seeing The Herb Doctor:
*
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Not just because you love us!
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10
Please list any known drug allergies.
This is important.
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11
Have you ever had (Please check all that apply):
You don't have to currently have these conditions. We just want to know about your past.
Anemia
Asthma
Arthritis
Cancer
Gout
Diabetes
Emotional Disorder
Epilepsy Seizures
Fainting Spells
Gallstones
Heart Disease
Heart Attack
Rheumatic Fever
High Blood Pressure
Digestive Problems
Ulcerative Colitis
Ulcer Disease
Hepatitis
Kidney Disease
Liver Disease
Sleep Apnea
Use a C-PAP machine
Thyroid Problems
Tuberculosis
Venereal Disease
Neurological Disorders
Bleeding Disorders
Lung Disease
Emphysema
Other
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12
Women, how many times have you given birth?
Include still-births and miscarriages after 10 weeks.
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13
Any suspected food/environmental allergies?
*
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Not confirmed, only suspected.
Yes
No
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14
Where have you lived most of your life?
*
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Farm boy or city girl?
Farm/Rural
Suburb/City
Urban/Metro
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15
Have you had any surgeries?
*
This field is required.
Just so we know.
Yes
No
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16
Current Medications:
This is important to know!
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17
If yes to surgeries, please describe.
Major and simple.
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18
Current Supplements:
Include vitamins.
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19
Check any issues you currently have:
Only if you've experienced them in the past 12 months.
Indigestion or Heartburn
Bloating
Diarrhea
Irritable Bowels or Colitis
Yeast Infection
Skin Rash or Hives
Skin Dry or Oily
Headaches
Seizures
Dizziness/Vertigo
Seasonal Allergies
Hemorrhoids
Cold Sores
Overweight
Underweight
Blood Sugar Issues
Ulcers
Cancer
Kidney Disease
Liver Disease
Sleep Apnea
Insomnia
Thyroid Problems
Food Sensitivities
Respiratory Illness
Neurological Disorders
Bleeding Disorders
Mental Health Diagnosis
Emphysema or COPD
Anxiety, Fear, or Nervousness
Frequent Sinus Infections
Asthma
Autoimmune
Frequent Ear Infections
Joint Pain or Swelling
Chronic Fatigue
Thinning Hair
Hot Flashes
Irregular Periods
Shaking or Trembling
Feet/Ankles Swelling
Frequent UTIs
Muscle Cramps
Muscle Weakness
Difficulty Urinating
Low Libido
PMS
Kidney Stones
Other
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20
List any other health concerns.
Anything in particular bothering you?
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21
Exercise
*
This field is required.
It's okay if you don't.
Never
1-2 days
3-4 days
5+ days
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22
Eating following a diet
*
This field is required.
No judgement.
I have a loose diet
I have a strict diet
I don't have a diet plan
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23
Alcohol Consumption
*
This field is required.
Don't forget to consider the size of the glass.
I don't drink
1-2 glasses/day
3-4 glasses/day
5+ glasses/day
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24
Caffeine Consumption
*
This field is required.
A little coffee is okay, the whole pot is not.
I don't use caffeine
1-2 cups/day
3-4 cups/day
5+ cups/day
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25
Do you smoke?
*
This field is required.
We don't judge.
No
0-1 pack/day
1-2 packs/day
2+ packs/day
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26
Include other comments regarding your health.
Anything else we should know?
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