Client Intake Form

Client Intake Form

Buck Naked Plant Medicine
This is a detailed intake form and may take up to 30 minutes to fill out. By taking the time to do so with as much detail as possible- you gives me a wider picture of your health, which allows me to share with you as much information as I can. Thank you.
General Information
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Birthdate

MonthDayYear
Date
Gender
Preferred method of communication
Occupation
Relationship status
# of Childern
Are you pregnant or trying to concieve?
Intention of this Appointment
Please describe the major concerns you would like to have addressed:
Do you have any other health issues? If so, please describe:
Are you on any medications? If so, drug name/ dosage/ reason for taking:
Are you currently taking any herbal supplements? If so, what type/ dosage/ reason for taking:
Are you currently seeing any other healthcare practitioners, including alternative healing modalities? If so, what type and have you noticed improvement?
Personal History
Please list any major illnesses, injuries, accidents, hospitalizations, or operations you have had, including approximate dates:
Allergies

Please list/describe
Drug allergies:
Food Allergies:
Environmental allergies:
Have you had any adverse reactions to any herbal medicine or supplements?
Family Health History

Please describe any health issues, or, if passed, please list cause
Mother
Father
Siblings
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Daily Living Reflections
Please describe the overall experience of your home/ family life including whom you live with:
Please describe the overall experience of you work/ job life:
Please describe any particular stress related to your family/home, work, or personal life:
Please describe the nature of your dream life. Do you remember your dreams? Do you have reoccurring dreams? How big of a role do your dreams play on your everyday life?
What are your hobbies, interests, skills, and favorite pastimes?
Physical Activity
Please list the kinds of exercise you get and how often:
Dietary Habits
Please tell me about your diet in as much detail as you can.
Do you drink alcohol? If so, how much and how often:
Do you drink caffeinated beverages? If so what/ how much?
Have you ever had/ currently have an eating disorder?
What did you eat and drink yesterday?
What are your favorite and least favorite flavors?
Past and Present Health Challenges

Gastrointestinal

Rows	Present	Past	Unsure
abdominal pain
nausea/ vomiting
flatulence/ gas
constipation
diarrhea
bloody stools
change in bowel habits
hemorrhoids
indigestion/ heartburn
diverticulitis
colitis
liver condition
gallstones
change in weight

Please elaborate if necessary

Urinary/ Kidney

Rows	Present	Past	Unsure
painful urination
frequent urination
water retention
kidney stones
low back pain
inability to hold urine
inability to empty bladded
blood in urine

Please elaborate if necessary:

Cardiovascular

Rows	Present	Past	Unsure
high blood pressure
low blood pressure
heart murmur
palpitations
pain in heart
high cholesterol
poor circulation
swelling in ankles and feet

Please elaborate if necessary:

Muscle/ Joints

Rows	Present	Past	Unsure
backache
osteoporosis
arthritis
bursitis
gout
broken bones

Please elaborate if necessary:

Eyes, ears, throat, nose, head

Rows	Present	Past	Unsure
earaches
sinus infection/ congestion
hay fever/ allergies
eye pain
sore throat
herpes/ cold sores
jaw/ tooth pain
hearing loss
impaired vision
tonsillitis
headaches
dizziness/ fainting

Please elaborate if necessary:

Respiratory

Rows	Present	Past	Unsure
chest pain
difficulty breathing
asthma/ wheezing
lung congestion
coughing
coughing blood

Please elaborate if necessary:

Skin

Rows	Present	Past	Unsure
rashes/ skin eruptions
dryness/ eczema/ psoriasis
itching
boils/ acne
bruise easily
varicose veins
oily skin
oily hair
dry skin
dry hair

Please elaborate if necessary:

Childhood Diseases

Rows	Present	Past	Unsure
Chicken pox
Rheumatic fever
Mumps
Measles
Scarlet fever
Tonsillitis
Strep throat
Whooping Cough
Other

Please elaborate if necessary:
diabetesepilepsyhyper thyroidhypo thyroidjaundicecancerclotting defectsHIV/ AIDSchronic fatigue/ epstein-barralcoholism/ drug addictionmental illnesshepatitis A, B, or C
Body Temperature
Are you hot or cold natured?
What is your favorite weather?
Are any parts of your body more hot or cold than other parts? If so, where?
Constitution

Please rate these by scale below

	1	2	3	4	5	6	7

1 is Hot, 7 is Cold

	1	2	3	4	5	6	7

1 is Damp, 7 is Dry

	1	2	3	4	5	6	7

1 is Relaxed, 7 is Tense

Emotional

Rows	Never	Rarely	Sometimes	Often
angry
enthusiastic
inspired
sad
anxious
fearful
lethargic
thinking deeply
attentive
forgetful
manic
worried
depressed
grumpy
mood swings
dreamy
happy
joyful
nervous

Please elaborate if necessary:
Other
How is your short term memory? Long term memory?
How is your oral health? cavities? Gum bleeding? Bad breath? Dry mouth? anything else?
How are your sleep patterns? How many hours per sleep do you get per night, on average? Do you need any special conditions to sleep well?
Elimination
How often do you have a bowel movement?
What is the color and consistency?
Are your bowel movements really strong smelling?
Is your need to have a movement urgent?
Men's Specific Health
Do you have or have you ever had any sexually transmitted disease? If so, what and when?
How is your libido?
Do you suffer from impotence or prolonged erections? If so, describe:
Is it ever painful to urinate or ejaculate? If so, describe:
Do you have any concerns about your sexuality or vitality?
Women's Specific Health
Do you have or have you ever has any sexually transmitted disease? If so, what and when:

General

Rows	Present	Past	Unsure
breast pain
uterine fibroids
cycts
cervical dyspepsia
endometriosis
pelvic pain
infertility
vaginal infections
anemia
unusual vaginal discharge
miscarriage
painful intercourse
tumors
unusual PAP
vaginal dryness

Please elaborate if necessary:

Menstrual Cycle

Rows	Present	Past	Unsure
irregular cycles
heavy bleeding
spotting between cycles
absence of cycle
mood swings around cycle
acne
bloating
painful bleeding

Please elaborate if necessary:
bright redclotsdark coloredheavy flowprofuse flowscant flowreddish brownOther
Please elaborate if necessary:
Menopause
Do you use birth control? If so, what method?
How often do you menstruate? How many days do you bleed?
What is your relationship to you cycle?
Please list any pregnancies you have had, including abortion or loss, or child birth date:
If you have had children how was labor and delivery?
Is there anything else you would like to add?
That's all! Thank you for taking the time to fill out this detailed form. It gives me the information that helps me to view your health from a wide scope. I look forward to meeting with you.
Should be Empty:

Client Intake Form

General Information

Intention of this Appointment

Personal History

Allergies

Family Health History

Daily Living Reflections

Physical Activity

Dietary Habits

Past and Present Health Challenges

Body Temperature

Constitution

Emotional

Other

Elimination

Men's Specific Health

Women's Specific Health

That's all! Thank you for taking the time to fill out this detailed form. It gives me the information that helps me to view your health from a wide scope. I look forward to meeting with you.