M.H.A Pre-Consultation Form

M.H.A Pre-Consultation Form

Please fill out all relevant questions. Its important to note that individuals are required to be open and honest when completing. This will afford me better insight on how best to assist you. Your information will be kept confidential.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

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

MonthDayYear
Date
Height
Weight
Are you an existing client
- Current health practitioner(s):
- Do you have any current health concerns or pre exisiting medical conditions
- If yes, please describe your health concern(s) in detail:
- On a scale of 1-5, 5 being the worst how would you rate your discomfort level.
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is Manageable , 5 is Severe
- Please list all your current prescription medications, herbs, or supplements (incl. birth control pills, pain medications, laxatives, etc.) Include dosage and frequency for each one.
- Please list all your current over-the-counter medications, herbs, or supplements (incl. birth control pills, pain medications, laxatives, etc.) Include dosage and frequency for each one.
- Have you ever had an adverse reaction to any medication or herb?
- Do you have any allergies or sensitivities? (e.g., foods, medications, herbs)
- If yes please specify.
- Dental History (if known). Please provide details on the number of silver fillings, composite fillings, root canals or other dental work you currently have. Also note if you have current dental problems that need attending to.
- Surgical History. Please list any surgical procedures you have had and the time period in years or months or weeks since you had this surgery.
- Do you have a family history of any medical conditions?
- If yes please specify relation and condition.
- Last menstrual cycle (please include date and description)
  
  MonthDayYear
  Date
- Are you cycles regular (28 days)?
- If no what your average cycle length?
- Please provide more information, so I can get an idea of what a normal cycle looks like for you.
- Are you actively trying to become pregnant?
- If yes please provide any information that may help me to best assist you. i.e. if you are taking any medicines, supplements, IVF treatments etc.
- Have you given birth during the past 12months?
- If yes please select all that apply.
- Please provide details of your birthing journey.
- Are you currently breastfeeding?
- Use the space below to provide any information regarding your postpartum journey, that you feel may help me to assist you.
- In order to gain a better viewing of who you are and how best I can assist you on your plant medicine journey, I need something from you.
  
  Remember this a no judgement, strictly confidential form so please be transparent when completing each section. Help me help you!
  
  It is a requirement that persons seeking to use my services provide a brief but truthful insight into what a typical day in your life looks like. This will include details that involve your work life, family, regular commitments, social and leisure activities etc.
  
  Why do I need this information?
  
  This information will enable me to pinpoint any areas that might be allowing for disruption within the body, as it is our everyday routines and choices that have the greatest impacts on our livelihood.
  
  More often its the small things that we often overlook, that over time cause us the biggest distress and imbalances. Busy lifestyle leaves minimal time for rest, and conscious fueling. So with this in mind tell me what you day looks like.
- An average day for me looks like......
- Do you work?
- Tell me about your work? What you do or did, do you / did you enjoy it etc?
- How many hours do you work a week?
- How do you spend your leisure time?
- Rate your daily stress levels
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is Low, 5 is High
- Please identify and detail your reasons for this
- Is sleep / rest a issue for you?
- Please describe your sleep patterns.
- Which food group(s) best describe your preferred consumer habits. Tick all that apply
  
  Other
- If selected "other" please specify
- Do you prepare and cook all your meals?
- If yes, how often do you prepare and cook your meals.
- If no, explain what your food choice would be on a day that you decide not prepare or cook your own food.
- How much water (h20) do you consume daily?
- Daily beverage choices: Tick all that apply
  
  Other
- If selected "other" please specify.
- Please use the space below to demonstrate what your daily food and beverage intake may look like:
- Do you smoke?
- If yes please include all details (choice of smoke, regularity etc)
- Do you drink alcohol?
- If yes how much do you drink on average and how often.
- Do you take any other substances (legal or illegal) that may alter your natural state?
- If yes please specify
- How often do you have a bowel movement?
  
  Other
- Please give details below (inc. stool amount and consistency)
- Do you need assistance to stimulate bowels?
- If yes please specify any medications (prescribed or over counter products) or methods used.
- Do you have trouble releasing water (urinary)?
- If yes please explain, be sure to include any medications or methods used to help address this issue.
- Do you need to get up out of bed & urinate several times at night?
- Please list any other details that you feel are relevant to this lifestyle section below.
- Is key for making sure our bodies stay in a flow state.
  
  When you engage in regular movement you provide the necessary support for multiple bodily systems (for example the lymphatic and circulatory systems).
  
  Regular movement helps to strengthen our physical body, ensuring adaptability, whilst encouraging personal evolution on a physical and cellular level. And the best bit is that movement doesn’t have to be strenuous, it doesn't have to be specific just allowing your body to move and flow is enough.
  
  However if you are looking for somewhere to start activities such as Tai Chi, Qi Gong, Yoga, stretching, walking, dance, all help to maintain and encourage flow.
  
  Are you moving enough? Let's find out..
- Do you have a physical or mental impairment that stops / limits you from regular movement?
- If yes, please specify
- Have you tried any HMPs (Holistic Movement Practices)
  
  Other
- If selected "other" please specify
- Do you engage in regular non strenuous movement (gym, home, outdoor adventures, swimming, walking the dog etc)
- If yes please explain
- Do you engage in any other physical activities?
- If yes please list any details below.
- How often do you engage in the above physical activities?
- Plant medicine is a unique experience that is delivered and administered according to the client and the spirit and/or qualification of the herbal worker.
  
  My Role as a Plant medicine worker is to provide clients with knowledge and herbal offerings that support and allign to your (the client) individual journey (needs) - be it to maintain wellness or bring the body back into ease, through your openness and my connect we will work together to find what's right for you.
- What are your reasons for contacting MHA?
- Focus area (Select all that apply)
  
  Other
- Have you previously used plant medicine and/or holistic therapies?
- If yes, please specify which herbs or treatments you have used.
- What is your preferred method of plant medicine.
- Are you seeking a custom blend?
- Have you tried any of these alternative therapies?
  
  Other
- Please give details of your experience below.
- What are your goals for this consultation?
- Preferred Method of Consultation
- Please select your desired appointment time/date and I will do my best to accommodate.
- Feel free to share any additional information that is relevant to your enquiry. Additional comments or questions also welcomed.
- Should be Empty: