Adult Intake form
Tamra L Speakman, CHWP, herbalist
760-609-0954
Client Information:
Name:
Address:
Phone:
Skype:
D.O.B.:
Sex:
age:
Nationality:
Height:
weight:
Religion:
Employer:
Job Title:
Hours worked: week:
day:
Toxic chemical exposure at work: y/n
list:
Allergies to food, medication, plants, animals or synthetics:
Other sensitivities noted:
Birth info: (please provide what you can remember)
Gestational age:
Birth weight:
length:
(Circle all that apply)
Natural, C-section, induced, epidural, pain medications, hospital, midwife, homebirth, birthing center, fetal
monitoring,
Other:
Breast fed y/n, how long:
age weaned:
Formula fed y/n, type:
Did Milestones develop normally in childhood y/n
Environment: (circle one)
House, apartment, mobile home,
Age of home:
other: (please explain):
known toxins: (lead paint, formaldehyde, etc.):
1
How often are pesticides used?
Have you had infestations of rodents or roaches?
Have you ever had water leaks from roof or pipes?
Do you have any signs of mold?
y/n if yes please describe
Do you use toxic cleaners (bleach, sprays etc.)?
Do you use air purifiers?
How many indoor plants:
Please list pets:
how often bathed and by whom:
Health Habits:
Please complete week long diet analysis form and bring with you to consultation.
How often do you exercise?
Household chores:
Hours watch T.V. per day:
Do you nap?
How often do you have a bowel movement?
How many hours of sleep do you get a night?
Do you pray and read Bible regularly: y/n
Type:
hours per week:
Hours use computer per day:
Time in sun per day:
Family Health History:
Mother living y/n, Father living y/n, siblings living y/n,
(Please give age and cause of death):
Circle any family history:
Cancer, type:
Heart disease, Hypertension, Fibromyalgia, lupus, Multiple Sclerosis, Mental disorder, Genetic disorder,
Diabetes, Allergies,
Other:
What is your main goal or desire from this consult?
Are you willing to take charge of your own health and make lifestyle changes when necessary? Y/n
Vaccination History:
Vaccination Reaction noted symptoms and dates:
History of illness:
Have you ever been to an alternative medicine or holistic medicine provider: y/n
Please list type with dates:
Health care providers (including family physician) or Holistic professionals you are currently seeing:
Is your physician open to Holistic, alternative treatments: y/n
Childhood illnesses: (List and include dates)
Other past illnesses or symptoms:
2
Current medical diagnosis:
Who diagnosed and when:
Current symptoms and complaints:
What makes them worse?
What makes them better?
Current Medications: (name, dose and how long taken)
Current supplements or herbs: (name, dose and how long taken)
Signs and symptoms:
(Please write down any symptoms related to system or organs)
Digestion and elimination:
Abdominal pain:
Bowel:
Bladder:
Liver, Gallbladder, Pancreas:
Mental, emotional:
Depression:
Stress:
Fatigue:
Insomnia:
Respiratory:
Lungs:
Sinuses, throat:
Congestion, allergies:
Skin and mucous membranes:
Reproductive:
Menopause:
Fertility:
Prostrate (male):
Menstrual problems (female):
regular cycles: y/n
Menstrual Cramps, pain, abnormal bleeding:
Musculoskeletal:
Spinal pain:
Muscle pain:
Spasms:
Injuries:
Circulatory:
Heart: Blood Pressure:
Other symptoms:
3
4