New Client Intake Form
Congratulations! You've taken the first step by booking your initial herbal consultation! Your next very important step is to complete this form. The information you provide here is critical in helping me learn about your unique story and prepare for your consultation. Please submit this form no later than 1 WEEK PRIOR to your appointment.
Personal Information & Consultation Goals
Name
*
First Name
Last Name
Email
*
Pronouns
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
*
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Month
-
Day
Year
Date Picker Icon
Birthplace
City/State/Country (For use in consulting your astrological birth chart)
Birth Time
Hour & Minute (For use in consulting your astrological birth chart)
Emergency Contact
*
Name & Phone
How do you occupy your days?
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What is your primary reason for pursuing an herbal consultation?
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What is your ideal outcome from your initial consultation?
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What are your long-term goals or expectations for working with herbs beyond the initial consultation?
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Which herbal medicine interactions are you open to trying?
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Herbal Teas
Alcohol Extract Tinctures
Non-Alcoholic Tinctures
Topical Alcohol Liniments
Topical Salves
Flower Essences
Smoke Bundles
Sitting With Plants
Spiritual Plant Wisdom
Astrological Herbalism
Growing Your Own Herbal Medicine
Making Your Own Herbal Medicine Preparations
Other
What is your previous experience working with herbal medicine?
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Do you have any specific plants you have worked with or feel drawn to?
Physical Health History
Please list any present physical health concerns for which you are currently being treated by a physician.
Please list any Medications, Vitamins, Supplements, Herbs or Homeopathics you are currently taking and for what.
Please list any other natural physical healing modalities you use on a regular basis (Acupuncture, Massage, Naturopathy, etc.).
Please list any allergies or sensitivities you have to Medication, Food, Plants, Chemical or Environmental Substances.
Please list any previous notable physical health concerns, injuries or surgeries.
Please list any family history of hereditary medical conditions (diabetes, cancer, dementia, etc.).
Please submit any additional information you feel is relevant to your unique health story.
How do you practice self-care for your body?
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What gender best describes your bodily reproductive/ hormonal system (for purposes of appropriate care)?
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Female
Male
Both Female & Male
Prefer not to say
Please attach any recent bloodwork and/or lab reports (done within the past year).
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Mental, Emotional & Spiritual Health
Please list any mental, emotional or spiritual health concerns for which you would like to explore plant medicine.
How do you practice mental, emotional & spiritual self-care?
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Please list any mental, emotional or spiritual healing modalities you practice on a regular basis (religion, meditation, sound healing, reiki, etc.)
Do you feel balanced between your mind, body & spirit?
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Yes
No
Unsure
Body System Energetics Inventory
Body System Energetics Inventory
Please complete the following inventory entirely, doing your best to note any conditions you’re experiencing now or have had recurring off and on for at least the past six months. (Don't worry about the "E/D" section headings, simply choose which conditions are present for you in all sections). The conditions listed are not necessarily good or bad, but noting which ones are present can help us evaluate how your unique body works, if there may be an imbalance and which herbs may help or aggravate your system. You may feel the conditions of certain systems don’t pertain to your stated purpose of the consultation, however our bodies are made of multiple complex systems working together and an imbalance in one can (and usually does) affect all other systems. This evaluation is based on the Principles and Practice of Constitutional Physiology developed by late herbalist, Michael Moore, as taught to me by my mentor, herbalist Ginger Webb, and is used with their permission.
Upper Gastrointestinal System
Includes Mouth, Salivary Glands, Esophagus, Stomach, Duodenum
Upper GI - E
*
Sometimes nausea in morning or before a delayed meal
Excess salivation/wet mouth
Stomach Ulcer
Strong, demanding hunger
Rapid evacuation of bowels in morning
Prefer high protein/fat foods
Red-tipped and/or sore tongue
None
Other
Upper GI - D
*
Coated tongue, bad breath and/or bitter taste in the morning
Mouth frequently too dry
Duodenal ulcer
Sometimes foul burps
Butterflies in stomach
Seldom eat breakfast
Often don't finish meals
Often eat to calm down
Receding gums
Frequent use of alcohol
Frequent poor appetite
Slow evacuation of bowels
Sometimes nausea in the evening
Frequent indigestion, especially at night
Frequent mouth or cold sores
Sometimes difficulty swallowing
Don't like high protein/fat foods
Food sensitivities and/or issues with certain food combinations
None
Other
Lower Gastrointestinal System
Appendix, Large Intestine, Small Intestine, Rectum, Anus
Lower GI - E
*
Loose stools with gas
Digestion excessively rapid/dumping syndrome
Loose stools when tired/stressed
Dark-colored, soft stools
Defecation urge shortly after eating
Rapid elimination upon defecation
Beginning of stool in single bowel movement is well-formed but majority is semi-formed
None
Other
Lower GI - D
*
Frequent constipation
Light-colored, hard stools
Intestines often bloated
Constipation with gas
Constipation with hemorrhoids
Constipation with hard, marbly stools
Constipation with fully formed stools
Constipation alternated with diarrhea
Frequent need for laxatives
Tongue often coated
None
Other
Liver/Biliary System
Liver, Gallbladder, Bile Ducts
Liver/Biliary - E
*
Moist, sometimes oily skin
Hives from food or drugs
Crave protein/fats
Fever & sweating when sick
Elevated cholesterol
Hypertension
None
Other
Liver/Biliary - D
*
Dry, scaly skin and mucosa
Sinus allergies or asthma
Crave fruit or sweets
Frequent trouble digesting fats
Acne on face AND buttocks
Low blood sugar symptoms
Prefer sweet foods
Frequent use of alcohol
Work with solvents
Psoriasis, eczema or dermatitis
Frequent minor illnesses
Don't sweat when sick
Had hepatitis in past
None
Other
Kidney/Renal System
Kidneys, Ureters
Kidney/Renal - E
*
Standing too quickly makes pulse roar in ears (orthostatic hypertension)
Moderate high blood pressure, crave fats
Urine usually darker
General hypertension
Warm, moist skin
Water retention, especially with sodium intake
None
Other
Kidney/Renal - D
*
Standing too quickly causes faintness, dizziness (orthostatic hypotension)
Wake up at night to urinate (especially more than once)
Frequent flushing or blushing
Water retention with changes in weather temperature/humidity
Moderate low blood pressure, crave sweets
Frequent thirst
Craving for salt
Urine always light colored
General low blood pressure
None
Other
Lower Urinary Tract System
Bladder, Urethra
Lower UT - E
*
Infrequent urination, copious amounts
None
Other
Lower UT - D
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Frequent urination, small amounts
Sometimes dribble urine after urinating
Frequent bladder infections
Demanding and sudden need to urinate
Mucus in urine
Dull ache after urination
(Males) Benign prostatic hypertrophy (enlarged prostate gland)
None
Other
Respiratory System
Nose, Pharynx, Larynx, Trachea, Bronchi, Lungs, Diaphragm
Respiratory - E
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Easy coughing of mucus
Sometimes hyperventilate
None
Other
Respiratory - D
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Shortness of breath when standing or walking
Tobacco smoker
Difficulty swallowing mucus
Rapid, shallow breather
Sometimes wake up choking or gasping for breath
Yawn frequently
Frequent chest colds
None
Other
Cardiovascular System
Heart, Arteries, Veins, Capillaries
Cardiovascular - E
*
Slow, strong pulse
Frequent physical activity
Warm bodied
Hands warm, sweaty
Heart palpitations as an adolescent (prior to starting menses for females)
Hypertension, responds to diuretics
None
Other
Cardiovascular - D
*
Fast, light pulse
Cold bodied
Sometimes dizzy or faint
Hands cold, clammy or dry
Hypertension, does not respond to diuretics
None
Other
Lymphatic/Immune System
Tonsils, Adenoids, Thymus, Spleen, Bone Marrow, Lymph Vessels, Lymph Nodes
Lymphatic/Immune - E
*
Recuperate quickly from illness
Injuries heal quickly
Easily digest fats
None
Other
Lymphatic/Immune - D
*
Recuperate slowly from illness
Injuries heal slowly
Eczema, dermatitis
Asthma or hay fever
Arthritis or rheumatism
Difficulty digesting fats
None
Other
Skin/Mucosal System
Skin, Mucous Membranes
Skin/Mucosal - E
*
Skin eruptions superficial, come to a head
Oily scalp or hair
None
Other
Skin/Mucosal - D
*
Skin eruptions deep, not coming to a head
Skin on trunk is dry
Dry scalp or hair
Cracks, fissures on heel, feet, slow healing
Sores/cracks on mouth, anus or vagina
Lips often dry, chapped
Food often causes intestinal pain passing through
Get sore throat easily/often
None
Other
Female Reproductive System
Female Repro - E
*
Sweat freely with strong scent
Oily skin, facial acne
Menstrual cycle less than 28 days
Water retention before menses in hips & breasts
Typically crave fats/proteins before menses
Sides of breasts tender before menses
Palpitations before menses
Menstruation short, defined, few cramps
Start menstruating early with altitude change
None
Other
Female Repro - D
*
Dry skin, cold hands and feet
Menstrual cycle more than 28 days
Water retention before menses in hands and feet
Typically crave sweets before menses
Sometimes skip menstruation periods
Menses slow starting with cramps
Menstruation lengthy, frequent cramps
Frequent Class II Pap Smears (atypical but not suspicious)
History of Pelvic Inflammatory Disease, cervicitis
Miscarriages, problems with pregnancy
Start menstruating late with altitude change
Body doesn't tolerate birth control pills
Frequent yeast infections/candida overgrowth
None
Other
Male Reproductive System
Male Repro - E
*
Sweat freely with strong scent
Oily skin, facial acne
None
Other
Male Repro - D
*
Dry skin, cold hands and feet
Frequent cannabis user
Pain or ache after orgasm
Benign prostatic hypertrophy (enlarged prostate gland)
Difficulty maintaining erection even when sexually aroused
None
Other
Musculoskeletal System
Musculoskeletal - E
*
Tight muscles and tendons in neck, back & legs
Often need massage/hot tub/body work
Muscles are overstimulated when used and taut when at rest
None
Other
Musculoskeletal - D
*
Joint aches often
Sense of weakness in shoulder or legs
Notable lethargy after eating
None
Other
Dosha Quiz
Dosha Quiz
In Western Herbalism we often borrow from Eastern herbal traditions to help give us language and a framework for complex ideas. I’ve found that the Dosha framework of the Ayurvedic medicine tradition to be helpful for understanding our bodies and the daily decisions of care for them. The three Dosha body constitutions are Vata (V), Pitta (P) and Kapha (K) and each person is born with their own unique ratio of the three, typically with a leaning towards one constitution, but sometimes two equally. As we age and through lifestyle choices and circumstances, our Dosha ratios can become imbalanced, affecting our wellbeing. Rebalancing your unique Dosha can be a key component to vitality and herbal medicine along with lifestyle changes can help you do that. This quiz is designed to help determine your unique Dosha ratio and will help us discover any imbalances. When selecting your answers below, try not to overthink but reflect on what is "normal" for you - perhaps what you were like as a child or prior to a trauma event. For example: maybe your frame was "slender" as a child but as an adult you've had a sedentary, stressful job which makes your frame currently "moderate" or "large". When you take the quiz, please feel free to jot down any notes or questions for us to discuss together. The format of this Dosha quiz was developed by herbalist Natalie Vickery and is used by permission.
Body Frame
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Slender (V)
Moderate (P)
Large (K)
Normal
Current
Body Weight
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Low (V)
Moderate (P)
Heavy (K)
Normal
Current
Skin
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Dry, rough, cool, brown, black (V)
Soft, oily, warm, fair, red, yellow (P)
Thick, oily, cool, pale, white (K)
Normal
Current
Hair
*
Black, dry, kinky (V)
Soft, oily, yellow, early gray, red (P)
Thick, oily, wavy, dark or light (K)
Normal
Current
Teeth
*
Protruded, spaces between, crooked, gums thin (V)
Moderate size, soft gums prone to bleeding (P)
Large size, strong, white, full or crowded (K)
Normal
Current
Eyes
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Small, dry, active, brown, black (V)
Sharp, penetrating, green, gray, yellow (P)
Big, blue, thick eyelashes (K)
Normal
Current
Appetite
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Variable, low (V)
Good, sharp, excessive (P)
Slow but steady (K)
Normal
Current
Thirst
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Variable (V)
Excessive (P)
Slight (K)
Normal
Current
Disease Tendency
*
Nervous disorders, pain (V)
Heat, infection, inflammation (P)
Excess water, mucous (K)
Normal
Current
Elimination
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Dry, hard, constipated (V)
Soft, oily, loose (P)
Thick, oily, heavy, slow (K)
Normal
Current
Physical Activity
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Very active (V)
Moderate (P)
Lethargic (K)
Normal
Current
Mind
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Restless, active, curious (V)
Aggressive, intelligent (P)
Calm, slow, receptive (K)
Normal
Current
Emotional Excesses
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Fearful, insecure, anxious (V)
Aggressive, irritable, jealous (P)
Greedy, attached, self-centered (K)
Normal
Current
Faith
*
Wavering, changeable (V)
Determined (P)
Steady, loyal (K)
Normal
Current
Memory
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Recent memory good, past memory poor (V)
Sharp (P)
Slow but prolonged (K)
Normal
Current
Dreams
*
Flying, jumping, running, fearful (V)
Fiery, angry, passionate, colorful (P)
Watery, ocean, swimming, romantic (K)
Normal
Current
Sleep
*
Scanty, interrupted (V)
Little, but sound (P)
Heavy, prolonged, excessive (K)
Normal
Current
Speech
*
Fast, chaotic, uninterrupted (V)
Sharp, clear, cutting (P)
Slow, monotonous, sing-song (K)
Normal
Current
Spending Habits
*
Spend quickly, impulsively (V)
Spend moderately and methodically (P)
Spend slowly and save (K)
Normal
Current
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