Intake Form

Intake Form
Welcome & Instructions
Gentle, whole-person herbal support
Welcome. This intake helps me understand what your body has been through and how I can support you. Take your time. It is okay to skip anything that does not feel relevant. You can save and return later.
Client Information
Date of birth

MonthDayYear
Date
Street address
City
State
Zip
Contact & Communication Preferences
Email
example@example.com
Preferred contact method
Preferred contact method
Okay to send reminders and check-ins?*

YesNo
Emergency Contact
Name
Relationship
Phone
Primary Care & Care Team
Do you currently have a primary care provider?*

YesNo
If yes, name and clinic
Other providers involved in your care therapist, OB/GYN, specialist, etc
Health History & Current Concerns
What brings you in today and what do you most want support with?
When did these concerns start and how have they changed over time?
Relevant medical history, diagnoses, or major health events
Surgeries, hospitalizations, or significant injuries
Allergies or sensitivities (food, meds, herbs, environment)
Medications, Supplements & Herbs*

Are you pregnant now?No
Medications, Supplements & Herbs*

Are you postpartum or have you recently given birth?* YesNo
Prescription medications (names, doses, timing)
Over-the-counter medications
Vitamins, minerals, or other supplements
Herbal products you currently use
Known reactions or interactions you have experienced
Lifestyle & Daily Rhythms
Typical daily routine (work, caregiving, movement, rest)
Movement or exercise you currently do
Tobacco, alcohol, or other substances
Hydration and caffeine habits
How is your stress level lately? (0–10)
Nutrition & Digestion
A typical day of meals and snacks
Cravings or patterns you notice
Appetite changes (e.g., low, moderate, high, varies)
Digestion notes (bloating, reflux, gas, bowel habits)
Food preferences, cultural or religious considerations
Sleep, Energy & Mood
How is your sleep right now? (falling asleep, staying asleep, waking)
Energy through the day (e.g., low, steady, afternoon dip, up-and-down)
Mood and emotional well-being
Anything you want support with related to anxiety, overwhelm, or focus
Women’s Health
Menstrual status (regular, irregular, perimenopause, menopause, not applicable)
If cycling, average cycle length and notable symptoms
Any current concerns related to gynecological health
Postpartum Section (Complete if you are postpartum or recently gave birth)
When did you give birth? (date)

MonthDayYear
Date
Type of birth (vaginal, cesarean, assisted, other)
Any birth complications you would like me to be aware of
Are you breastfeeding/body feeding?*

YesNo
Any feeding challenges or concerns (latch, supply, pain, mastitis history)
Current postpartum symptoms you want support with
How supported are you right now at home?
Anything from your pregnancy or birth experience you want me to know
Goals & Support
What would you most like to feel more of in your daily life?
What results or changes would feel meaningful over the next 1–3 months?
Which approach feels best for you? (gentle nourish-and-restore, structured with light accountability, not sure yet)
Any herbs or forms you prefer (teas, tinctures, capsules, powders)
Do you have preferences around cost or sourcing?
Trauma-Aware Space
Anything helpful for me to know so I can support you in a way that feels safe and respectful
Wrap-Up & Preferences
How did you hear about Alexander’s Herbs & Clinic?
Best days and times for appointments
Anything else you want to share before we meet

Thank you for sharing this information. I will review your intake before our session.
If anything changes before we meet, you can reply to your confirmation email with updates.
Should be Empty:

Intake Form

Welcome & Instructions

Contact & Communication Preferences

Emergency Contact

Primary Care & Care Team

Health History & Current Concerns

Lifestyle & Daily Rhythms

Nutrition & Digestion

Sleep, Energy & Mood

Postpartum Section (Complete if you are postpartum or recently gave birth)

Goals & Support