Please fill the intake form below, submit and I will be in touch!
Sam Lacombe - Clinical Herbalist
Type of product wanted
Tincture
Salve
Customized formulation
Herbs
Other
Please describe what you are looking for
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
DOB (Date of birth)
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
YYYY-MM-DD
Weight (lbs)
in lbs please
Biological Gender
*
Please Select
Male
Female
The gender when you were born
Actual Gender
Actual gender you identify yourself
What is(are) the primary reason(s) for wanting this product?
Medical History
Please check health conditions that you've experienced and/or that a provider has diagnosed.
Allergies
Do you have any allergies?
Yes
No
If yes, please list.
Do you have any drug allergies?
Yes
No
If yes, please list.
Medical History
Gastroenterology Related Medical History
Rows
Past condition
Ongoing condition
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease
Cardiology Related Medical History
Rows
Past condition
Ongoing condition
Heart Attack
Other Heart disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Rheumatic fever
Mitral valve prolapse
Other
Endocrine Related Medical History
Rows
Past condition
Ongoing condition
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Metabolic syndrome (pre-diabetes)
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Polycystic Ovarian Syndrome
Infertility
Weight gain
Weight loss
Eating disorder
Other
Nephrology Related Medical History cont.
Rows
Past conditon
Ongoing condition
Kidney stones
Gout
Interstitial cystitis
Frequent urinary tract infections
Frequent yeast infections
Erectile dysfunction
Sexual dysfunction
Other
Orthopedics Related Medical History cont.
Rows
Past condition
Ongoing condition
Osteoarthritis
Fibromyalgia
Chronic pain
Other
Immune System Related Medical History cont.
Rows
Past condition
Ongoing condition
Chronic Fatigue Syndrome
Autoimmune disease
Rheumatoid arthritis
Lupus SLE
Immune deficiency disease
Severe infectious disease
Poor Immune function
Other
Lung Related Medical History
Rows
Past condition
Ongoing condition
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Other
Cancer History
Rows
Past condition
Ongoing condition
Eczema
Psoriasis
Acne
Melanoma
Skin Cancer
Other
Cancer History Cont.
Rows
Past condition
Ongoing condition
Lung cancer
Breast cancer
Colon cancer
Ovarian cancer
Prostate cancer
Skin cancer
Other
Medical Health
Mental Health Condition History
Rows
Past condition
Ongoing condition
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Memory problems
Dementia/Alzheimer's
Parkinson's disease
Multiple Sclerosis
Seizures
Other
Gynecological History
Fibrocystic breasts
Endrometriosis
Fibroids
Infertility
Painful periods
Heavy Periods
PMDD
Menopausal patients
Hot flashes
Mood Swings
Concentration/Memory problems
Vaginal dryness
Decreased libido
Headaches
Weight gain
Loss of control of urine
Palpitations
Difficulty sleeping
Men's history
Prostate enlargement
Prostate infection
Change in libido
Impotence
Difficulty obtaining an erection
Difficulty maintaining an erection
Frequent urination at night
Urgency/Hesitancy/change in stream
Loss of urine control
Other
Oral Health
Implants
Tooth pain
Bleeding gums
Gingivitis
Floss regularly
Medication history
Rows
Currently
Past use
Rarely used
Never
NSAIDs (Advil, Motrin, Ibuprofen, Aspirin, etc.)
Tylenol (Acetaminophen)
Acid blockers (Tagamet, Zantac, Prilosec, etc.)
Antibiotics
Steriods
Oral contraceptives
Do you currently use any medication?
*
Yes
No
Unsure
Medications
*
List all prescription and over-the-counter medications you use
Do you currently take any herbs or supplements?
*
Yes
No
Unsure
Herbs/supplements
List all herbs or supplements you use
By checking this box, you confirm that the information you provided in this form is true, to the best of your knowledge.
*
Yes
Submit
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