Herbal Intake Form - Nourishing Roots Wellness
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Herbal Intake Form Shannon Muldoon- LMT, Certified Herbalist 223 Brink Road, Saylorsburg PA 18353 610-334-3392 * Nourishingrootswellness.com GENERAL INFORMATION Date: ___________ Name: ______________________________________________Age: _____ Birth date: ____ Address: ____________________________________________________________________ Street ____________________________________________________________________________ city state zip code Home Phone: ______________Cell Phone: ______________E-mail: ____________________ INTENTION FOR THIS APPOINTMENT Please describe the major health concerns you would like to have addressed: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ PERSONAL HISTORY Please list any major illnesses, injuries, accidents, hospitalizations, or operations: Date/s: Description: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Allergies Drug allergies (penicillin, aspirin, etc.): ____________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Food and environmental allergies (pollen, chemicals, etc.): _____________________________ ____________________________________________________________________________ ____________________________________________________________________________ Please list any adverse (negative) reactions you have experienced with herbal medicine/ supplements: ____________________________________________________________________________ ____________________________________________________________________________ FAMILY HEALTH HISTORY Mother:_____________________________________________________________________ Father:______________________________________________________________________ Sister(s):_____________________________________________________________________ Brother(s):___________________________________________________________________ Maternal Grandmother:_________________________________________________________ Maternal Grandfather:__________________________________________________________ Paternal Grandmother:__________________________________________________________ Paternal Grandfather:___________________________________________________________ DAILY LIVING PROFILE Please describe the overall experience of your family/home life, including whom you live with: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Please describe the overall experience of your work life: _____________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Please describe any particular stress related to your family/home, work, or personal life: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Physical Activity Please list the kinds of exercise you get and how often: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ DIETARY HABITS Please check any items included in your usual diet and approximate amounts daily or weekly: ___beans:_____________________________________________________________________ ___red meat:___________________________________________________________________ ___poultry:____________________________________________________________________ ___fish:_______________________________________________________________________ ___raw foods:__________________________________________________________________ ___vegetables:_________________________________________________________________ ___fruits______________________________________________________________________ ___nuts/seeds:__________________________________________________________________ ___grains:_____________________________________________________________________ ___fermented foods:_____________________________________________________________ ___seaweeds:___________________________________________________________________ ___tofu/ soy products:____________________________________________________________ ___butter:______________________________________________________________________ ___eggs:_______________________________________________________________________ ___cheese:_____________________________________________________________________ ___yogurt:_____________________________________________________________________ ___sugar:______________________________________________________________________ ___honey:______________________________________________________________________ ___water:_______________________________________________________________________ ___coffee:______________________________________________________________________ ___black tea:____________________________________________________________________ ___fast food/ fried food:___________________________________________________________ ___baked goods/desserts:__________________________________________________________ ___alcohol:_____________________________________________________________________ ___cigarettes:___________________________________________________________________ Please elaborate on any other dietary habits including any food allergies or intolerances: _________________________________________________________________________________ _________________________________________________________________________________ Please list what you drank/ate yesterday: Please list any regular medication (over-the-counter and/ or prescriptions) you are presently taking: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Please list any herbs or supplements you are currently taking: Past and Present Health Challenges Please mark an “o” for any past challenges and an “x” for any present health challenges: Gastrointestinal __abdominal pain __nausea/ vomiting __flatulence __constipation __diarrhea __bloody stools __change in bowel habits __hemorrhoids __belching/ indigestion/ heartburn __diverticulitis __colitis __liver condition __gallstones __change in weight Eyes, ears, nose, throat head __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 Urinary/ Kidney __painful urination __frequent urination __water retention __kidney stones __low back pain __inability to hold urine __inability to empty bladder __blood in urine Respiratory __chest pain __difficulty breathing __asthma/ wheezing __lung congestion __coughing __coughing __coughing blood Cardiovascular __high blood pressure __low blood pressure __heart murmur __palpitations __pain in heart __high cholesterol __poor circulation __swelling in ankles/ feet Skin __rashes/ skin eruptions __dryness/ eczema/ psoriasis __itching __boils/ acne __bruises __varicose veins Muscles and joints __broken bones __backache (upper/lower) __osteoporosis __arthritis/ bursitis/ gout Childhood diseases __chicken pox __rheumatic fever __other Other Condition __epilepsy __diabetes __clotting defects __hyper-/hypo-thyroid __jaundice/ hepatitis __bleeding tendencies __cancer __Sexually Transmitted Infection (please list) __alcoholism/ drug addiction __eating disorder __mental illness (Please list) GENERAL HEALTH (please describe briefly) How often do you have a bowel movement, and what is the typical consistency/color? How many hours of sleep do you average, per night? Please describe your energy level: Please add any other comments that may be helpful in an overview of your past or present health challenges: WOMEN’S SPECIFIC HEALTH Gynecological Please mark with a “0” any past health challenges and a “x” any present challenges: General __uterine fibroids __ovarian cysts __fibrocystic breast pain __endometriosis __cervical dysplasia __pelvic pain __painful intercourse __vaginal infection __vaginal itching/ discharge __pelvic inflammatory disease __sexually transmitted infection (please list) __difficulty conceiving/ infertility __anemia __sexual issues Menstruation __Irregular cycles __heavy bleeding __bleeding between cycles __painful cramps __absence of cycle __mood swings around cycle Menopause __break-through bleeding __hot flashes __mood swings __dry vaginal lining __osteoporosis __change in libido __hormone replacement therapy How often do you menstruate, and for how long do you bleed? __________________________________________________________________________________ Please lists the kinds of contraception you have used and for approximately how long: Obstetric (if applicable): Please list any pregnancies you have had including miscarriage or abortion date or child’s birth date:
