Herbal Consultation Intake Form

Herbal Consultation Intake Form

Please Note: This detailed intake form has many questions that may or may not pertain to your condition. This questionnaire is searching for potentially undiagnosed conditions and connections between ailments. Please feel free to answer only those questions you feel are important to your health concerns, or take the time to finish the full form. Any questions that you would rather discuss in person can be saved for future discussion. The price for an herbal consultation is $150.00 which includes a complete wellness workup and a wellness product. Please make this payment on the Rafiki Beauty and Wellness website.
- Full Name*
  
  First NameLast Name
- Date*
  
  MonthDayYear
  Date
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Contact Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Email Address*
  example@example.com
- Date of Birth*
  
  MonthDayYear
  Date
- Height
- Weight
- Relationship Status
  Ex: Single, Married, Divorced, etc.
- Children
  Ex: Yes, 2 or No
- Occupation
- Main Reason for Visit
  (Diagnoses, main complaints, and symptoms)
- Hobbies, Skills, Interests, Favorite Pastimes:
- Exercise: What type of exercise do you practice and how often?
- AyurvedicNaturopathPsychiatristMedical DoctorChiropractorSocial WorkerPsychologistBody WorkCounselingSpiritual CounselorHerbalistTraditional Chinese MedicineHomeopathPhysical TherapistOther
- Please describe your diet on an average day.
  Ex: Fruit, Vegetables, Seafood, Red Meat, Poultry, Butter, Milk, Cookies, Alcohol, Coffee, Soda, etc.
- Fill in the blank:
  I drink number of cups cups of water each day.
- I sleep number of hours hours each night on average.
- I exercise for number of hours hour(s), times per week times per week.
- LowHighOther
- How often do your bowels eliminate daily?
- YesNo
- If you answered "yes" to the question above, please explain.
- What nutritional supplements are you currently taking?
- What health concerns are you currently seeking help for?
- What medications, medical procedures, supplements, or therapies have you previously tried for your condition? Were any of these supplements or therapies helpful? If so, please note which ones were helpful.
- YesNo
- If you answered "yes" to the question above, please specify how often.
  Ex: 2 beverages a day or 5 beverages a week
- YesNo
- SmokingSnuffChewing TobaccoOther
- AidsAnginaArthritis (Rheumatoid)Arthritis (Osteo)Arrhythmia (Irregular Heartbeat)AsthmaAttention Deficit Disorder ADD/ADHDAutoimmune DisordersBenign Prostatic Hyperplasia (BPH)Bipolar Mood Disorder (Manic)Depressive DisorderBleeding DisordersCancerCardiac Arrest (Heart Attack)Celiac DiseaseChronic Obstructive Pulmonary DisorderCirrhosis of the LiverColitisCongestive Heart FailureDepressionDiabetesEczemaEndometriosisEpilepsyFatty Liver DiseaseFibromyalgiaGraves’ Disease (Hyperthyroid)Hashimoto’s Disease (Thyroiditis)HepatitisHigh Blood Pressure (Hypertension)Irritable Bowel Syndrome Crohn’s or ColitisKidney StonesLow Thyroid (Hypothyroid)LupusMultiple SclerosisObsessive-Compulsive DisorderPsoriasisUlcersOther
- Client Comments:
- AngerIrritabilityFrustrationAnxietyFearSadnessDepressionExcitementLaughterLack of EnthusiasmLack of JoyWorry
- If you checked any boxes above, please specify if these are problems with yourself or others.
- Abdominal Pain or discomfortAcid Indigestion, heartburn, or acid refluxBad BreathType option 4Bloating, belching or intestinal gasConstipation (bowel movements less than 1/day)Cravings for sugary foodsDiarrhea or loose stoolsFood AllergiesFood sits heavy on stomach after mealsGroggy feelings in the morningHard dry stoolsHemorrhoids or anal fistulaLoss of appetite or poor appetiteLoss of smell or tasteSensation of lump in throatStomach achesUnder weight or unable to gain weight
- Chronic or frequent coughCold soresExcess mucus productionFrequent InfectionsHay fever and respiratory allergiesItchy nose or earsPost-nasal dripSinus headachesSinusitis or chronic sinus congestionWheezing or shortness of breath
- Client Comments:
- AnemiaChest PainCold hands and feetFamily history of heart diseaseGingivitis or gum diseaseHeart PalpitationsHigh blood pressureHigh CholesterolHigh TriglyceridesIrregular heartbeat, arrhythmiaRapid heartbeatSwelling in lower extremitiesVaricose veins or spider veinsWounds that won’t heal
- Bladder InfectionsBlood in urineBurning or painful urinationDifficulty starting urinationExcessive perspirationFrequent pale urineFrequent urinationHistory of kidney stonesNight sweatsPain in the mid to lower backPuffiness under the eyeScant, dark urineUrinary incontinence (dribbling)Urinary tract infections (UTIs)Water retention and edemaSwollen lymph nodes
- Burning sensation in hands and feetCold hands and feetDark circles under eyesHair loss or thinningLack of staminaLoss of short-term memoryDry skinExcess weightExcess weight around the abdomenFatigue in the afternoonsFatigue, chronic or excessiveFeeling chronically stressed outFeeling exhausted, “burned out”Frequent thirstLow body temperature, easily chilledMental sluggishness, brain fogMood swingsMuddles thinking, confusionRestless disturbed sleepRestless dreams or nightmaresWaking up at night, unable to go back to sleepWaking up frequently at night
- Client Comments:
- Absent-mindednessAlcoholismAnxiety, nervousnessChronic muscle tensionDizziness or light-headednessExcitability, difficulty relaxingFeeling depressed or discouragedHeadachesTension headaches w/tight restricted feelingPounding headaches (like head exploding)Headaches around eyes and foreheadMigrainesLoss of memoryPanic attacksPeripheral neuropathyPoor concentrationShaky hands
- AcneArthritisBack painBrittle fingernailsEczemaGoutItching, skinJoint painLeg cramps or painsMultiple root canalsMuscle crampsNeck painOsteoporosisRashesRosaceaStiff, aching or painful musclesTeeth grindingTense musclesWeak legs, knees or ankles
- Difficulty urinationErectile dysfunctionInfertilityLack of sex driveLoss of self-confidence and driveNighttime urinationProstate problemsOther
- Client Comments:
- Craving for chocolate with periodsDepression with periodsEdema or bloating associate with periodsHeavy menstrual periodsHot flashes or night sweatsInfertilityIrritability with periodsLack of sexual driveMenstrual CrampsNursing (Currently)Painful menstruationPMSPost-menopausalPregnant (currently)Vaginal dischargeVaginal dryness
- Client Comments:
- Please add any additional information you feel may be helpful in evaluating your situation.
- Signature
- Please purchase the Herbal Consultation Payment via the website.
- Should be Empty: