Herbal Intake Form

Patient Name*

First NameLast Name

Sex assigned at birth*

Pronouns:

Patient Birth Date*

MonthDayYear

Patient Height*

Patient Weight*

E-Mail*

example@example.com

Primary Concern:*

Please list any drug allergies

Have you ever had (Please check all that apply)

Other illnesses:

Please list any Operations and Dates of Each

Please list your Current Medications

Exercise

Never1-2 days3-4 days5+ days

Nourishment

I have a loose dietI have a strict dietI don't have a diet planOther

Alcohol

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day

Caffeine

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day

Do you smoke? Tabacco or Cannabis

Include other comments regarding your Medical History

The purpose of this document is to clearly delineate the scope of practice assumed by Chelsea Wills and to ensure that no misunderstanding occurs between herself and any clients as to the expected course or progression of treatment.

Please read the statement below and sign your agreement with it:

California Senate bill sb-577, which was signed by the governor in September 2002, has profound implications for the practice of alternate forms of health care in California. Sb-577 enables alternative and complimentary health care practitioners to provide and advertise their services legally. However, they must also comply with certain requirements specified within the bill.

Here are some things unlicensed alternative health care practitioners are NOT allowed to do:

perform any form of surgery or any procedure that punctures your skin or harmfully invades your body.
use X-ray radiation
prescribe prescription drugs, or recommend that you discontinue drugs that were prescribed by a licensed physician
set fractures
treat wounds with electrotherapy
put you at risk of great bodily harm, serious physical or mental illness, or death.
imply in any way that they are licensed physicians.
In addition, an unlicensed alternative practitioner MUST DO the following things:

provide you with a statement, written in plain language that includes the following information: (1) that they are not a licensed physician and that their services are not licensed by the state; (2) a brief and clear description of the kind of services they provide and the reasoning behind it; (3) a description of their education, training, and experience.
ask you to sign an acknowledgement that you received the above written statement, and provide you with a copy of it. They must also keep a copy of your signed acknowledgment for three years.
The state of California does not at this time license herbalists. Chelsea Wills is not a medical doctor and does not claim to diagnose, treat, or cure any medical conditions or pathologies nor prescribe medicine nor in any way represent herself as so doing. For any condition, you are advised to seek care from an appropriate medical practitioner. Whether you choose to engage a medical practitioner or not for your care is your right and Chelsea Wills assumes no responsibility for your decision in this matter.

Informed Consent and Full Disclosure AgreementI have read and understood the statement above.I, the undersigned, assume all responsibility for decisions I make regarding my health, recognizing that (a.) no claims are made for herbal medicine, nutritional or dietary recommendations to treat or cure any medical condition (b) all information given is for educational purposes only (c) there is no implied or stated guarantee of success or effectiveness of any specific treatment plan or guidelines (d) I am free to act upon or disregard the recommendations of Stascha Stahl as I so choose. I hereby release Stascha Stahl from all responsibility or liability for my actions and any consequences thereof in the present time and in the future with no constraints. I hereby affirm that I consent and agree to the above statements of my own free will and request to engage the services of Stascha Stahl in a professional relationship pursuant to the statements herein.

General Client Information

Medical History

Lifestyle