Deborah Barbiere, Psy.D., L.Ac.
12 West 9th Street, Suite 1B-1
New York, NY 10011
212.620.7076
drdeborahbarbiere@gmail.com
deborahbarbiere.com
Please complete the information below, check the 5 conditions you would like addressed by your
HERBAL CUSTOM ACUTE PACK, and sign below. These formulas are for the temporary relief of
everyday short-term minor ailments ONLY!
Chronic or persistent symptoms need to first be evaluated by your physician. HERBAL CUSTOM
CONSTITUTIONAL PACKS to address chronic or persistent symptoms & underlying imbalances require
professional herbal consultation & follow-up. Contact Dr. Barbiere to schedule an appointment.
RED LOTUS HERBAL CUSTOM ACUTE PACK REQUEST QUESTIONNAIRE
PATIENT INFORMATION
Name:
Address:
Telephone number:
Email:
Date of Birth:
List any allergies
List any health conditions
Have you ever been
diagnosed with or treated
for any mental health
conditions? Please
explain.
List any medications,
supplements, or other
herbal remedies
Please check one:
YES - I am under a physician’s care for the above conditions
NO - I am not under a physician’s care for the above conditions
Please check one:
YES - I am interested in receiving more information about Dr. Barbiere’s services
(Acupuncture, Psychotherapy, Biofeedback, EFT/Tapping, Life Coaching, etc.)
NO - I am not interested in further information at this time
Please check one:
YES - I may be interested in scheduling an Herbal Consultation
NO - I am not interested in an Herbal Consultation at this time
CHOOSE 5
PLEASE DESCRIBE
cold/flu with sore throat
cold/flu with headache
cold/flu with sinus congestion
cold/flu with swollen glands
cold/flu/allergies with cough, respiratory
cold/flu with body aches
stomach/instestinal flu
cold/flu with skin rash
occasional heachache
run down/prevent cold or flu/immune boost
allergies with head/sinus congestion
occasional sleep problems
stomach upset, overeating, hangover
occasional constipation
mild PMS, i.e. cramping, irritability
UTI
occasional stress with muscle tension
occasional stress, overly sensitive
occasional low energy
stomach upset, overeating
stomach/intestinal upset, food contamination, travelling
hemorrhoids
stomach upset, heat in chest, excess spicy food
weak immunity, get sick easily, prevention
Please list any other temporary conditions not listed above:
I understand that these formulas are intended for short-term use and the temporary relief of minor symptoms. I will
not use if pregnant, nursing or if there are any significant changes in my health condition. I understand that these
products are not intended to diagnose, treat, cure or prevent disease.
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