Herbal Medicine Consultation Form

Thebox:V'Jinga Herbal Medicine Consultation Form

Please fill out this form to help us understand your health needs and concerns. Your information will be kept confidential.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth

MonthDayYear
Date
Occupation
What are your primary health concerns? (Select all that apply)

Digestive IssuesStress/AnxietyChronic PainSkin ConditionsRespiratory IssuesAbdominal painImmune SupportGastrointestinalMuscle/Joint PainEar, Nose, Throat, HeadCardiovascularUrinary/KidneyOther
Please describe your health concerns in detail in Listing:
Gynecological: Please mark with a “0” any past health challenges and a “x” any present challenges:

uterine fibroidsIrregular cyclesovarian cystsheavy bleedingfibrocystic breast painbleeding between cyclesendometriosispainful crampscervical dysplasiaabsence of cyclepelvic painmood swings around cyclepainful intercoursevaginal infectionMenopausevaginal itching/ dischargebreak-throughbleedingpelvic inflammatory diseasehot flashessexually transmitted infection (please list)__mood swingsdifficulty conceiving/ infertilitydry vaginal lininganemiaosteoporosissexual issueschange in libidohormone replacement therapyOther
Have you previously used herbal medicine?

YesNo
If yes, please specify which herbs or treatments you have used:
Do you have any allergies or sensitivities? (e.g., foods, medications, herbs)
Are you currently taking any medications or supplements? Please list.
Have you been diagnosed with any medical conditions?
What are the signs of the conditions are you currently experiencing?
Do you have a family history of any medical conditions?
What are your lifestyle habits? (Select all that apply)

Regular ExerciseBalanced DietSmokingAlcohol ConsumptionStress Management TechniquesOther
What are your goals for this consultation?
Preferred Method of Consultation

In-PersonPhoneVideo Call
Additional Comments or Questions
By filling out this questionnaire you are providing information to be used by Thebox:V'Jinga Holistic Spa assist you in creating a holistic lifestyle program. This information will not be used by any third party for any reason and will be kept strictly confidential. The questionnaire and follow-up consultation are not meant to substitute for a primary medical diagnosis or seeing a primary care physician or for treating, a serious or life-threatening conditions that should be seen by a qualified primary care medical doctor. I have read & understand the above. Disclaimer: This information is provided for educational purposes and is not intended as and must not be taken as a diagnosis for any disease.
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Thebox:V'Jinga Herbal Medicine Consultation Form