Client Intake Form - ArborVitae School of Traditional Herbalism

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Client Intake Form
Name__________________________________________________Today’s Date____________________
Address_______________________________________________________________________________
______________________________________________________________________________________
Telephone work______________________home_________________best time to call________________
Email________________________________________do you prefer to be contacted by email? y/n______
Date of Birth_________________height_____________weight________________
Gender ______________________
Pronoun used (he, she, they) _________________
Married or in long-term relationship? (y/n)___
# children_____ ages of children_________
Occupation___________________________________
Emergency contact:
Name:
Phone:
Please describe your current health concerns and/or goals (continue on back if necessary):
www.arborvitaeny.com
One Union Square West, Suite 309 New York, NY 10003
Please place mark next to any of the following symptoms with C that you experience currently or with P that you
have experienced significantly in the past:
____ Bloating / gas / indigestion
____ Constipation
____ Diarrhea / loose stools
____ Undigested food in stools
____ Nausea / motion sickness
____ Chest pain
____ Heartburn
____ Hot sensation
____ Cold sensation
____ Numbness
____ Poor circulation
____ Eyesight problems
____ Earaches / hearing problems
____ Headaches
____ Joint pain / inflammation
____ Muscle tension / pain
____ Severe injuries / accident
____ Excessive sweating / night sweating
____ Menstrual pain / PMS
____ Irregular menstural cycle
____ Menopause related symptoms
____ Sexual dysfunction
____ Urinary incontinence
____ Difficulty urinating
____ Urinary tract infections
____ Infertility
____ Dental health issues
____ Gum disease / bleeding
____ Skin condition
____ Bruise easily
____ Rashes
____ Teeth grinding
____ Frequent cold / flu
____ Asthma / wheezing
____ Sinus infections/issues
____ Depression
____ Anxiety
____ Anger / Short temper
____ Fear / Phobias
____ Poor memory
____ Foggy thinking
Please list any diagnosis or other major or recurring health related events in your life not covered above, including
date(s) (continue on back if necessary):
Family Medical History:
Please describe any relevant or major health related issues:
Father________________________________________________________________________________
Mother_______________________________________________________________________________
Siblings______________________________________________________________________________
Maternal Grandmother___________________________________________________________________
Maternal Grandfather____________________________________________________________________
Paternal Grandmother____________________________________________________________________
Paternal Grandfather_____________________________________________________________________
Other family members____________________________________________________________________
www.arborvitaeny.com
One Union Square West, Suite 309 New York, NY 10003
Medical Providers:
Please list all physicians and other healthcare providers (continue on back if necessary):
Name
Location
Type of Provider
Date of Last Appt
1.
2.
3.
Date of last physical exam______________Results________________________________________
_________________________________________________________________________________
Blood pressure____________ Cholesterol levels HDL: ______ LDL:_______ Triglycerides:_______
Do you have any environmental allergies?_______________________________________________
Food allergies?______________________ Chemical sensitivities? ___________________________
Allergies to certain medications?_______________________________________________________
Describe form and frequency of any regular physical activity or movement: _____________________
__________________________________________________________________________________
How many hours per night do you sleep?_______Describe sleep quality__________________________
Describe your energy level__________________
Is it consistently lower at certain times of day? (i.e. morning, afternoon)____________________
Describe your stress level ________________________________________________________________
What are the dominant one or two emotions in your life?________________________________________
_____________________________________________________________________________________
Do you like your work?___________________________How many hours per week do you work?______
Do you currently smoke tobacco?________If yes, how many cigarettes/day_________________________
Have you ever smoked in the past?__________For how many years?_______When did you quit?________
Do you currently drink alcohol?_________If yes, type, quantity, and frequency______________________
www.arborvitaeny.com
One Union Square West, Suite 309 New York, NY 10003
Do you smoke marijuana?______________ If yes how frequently? _______________________________
Use other recreational drugs?___________________________ Past drug use? ______________________
Dietary Information:
Please describe your typical meals. Be as specific as possible; for example, instead of “vegetables” describe type
and amount of vegetable; instead of “oil” describe type and amount of oil; instead of “bread” describe type and
amount of bread (whole grain, white, etc.). Include any beverages such as coffee, tea, herbal teas, juice, etc.
Breakfast______________________________________________________________________________
morning snacks_________________________________________________________________________
Lunch_________________________________________________________________________________
afternoon snacks________________________________________________________________________
Dinner________________________________________________________________________________
evening snacks__________________________________________________________________________
Daily water consumption (# glasses/day)___________Daily coffee consumption (# cups/day)___________
Other beverages (list amounts)_____________________________________________________________
List any recurring food cravings____________________________________________________________
Supplements and Medications:
List all herbs, vitamins, and dietary supplements you take regularly or were taking until recently, citing brand name
whenever possible (use additional space on back if necessary)
Product
Dosage
Frequency
1.
2.
3.
4.
5.
6.
7.
www.arborvitaeny.com
One Union Square West, Suite 309 New York, NY 10003
List all medications you take regularly or were taking until recently both prescription (P) and over the counter
(OTC) - use additional space on back if necessary
Product
P/OTC
Dosage
Frequency
1.
2.
3.
4.
5.
6.
7.
History of antibiotic use? (list frequency)__________________________________________________
www.arborvitaeny.com
One Union Square West, Suite 309 New York, NY 10003
Disclosure and Informed Consent
Only a physician can diagnose and treat disease, and prescribe medication. As herbalists
and not physicians, we do not diagnose or treat disease, or prescribe medication.
The human body has the innate power to heal itself. Without this power to self heal,
even the most advanced medications and surgical procedures would ultimately fail.
The role of the herbalist in the healing process is to consider the client as a whole
person, and to consult the client concerning changes in lifestyle, diet, and
supplementation in order to foster an increased state of balance and health, thus
maximizing the body’s self healing capabilities. Although rare and usually minor,
certain side effects, including allergic reaction, can sometimes occur from natural
remedies.
The ArborVitae School of Traditional Herbalism advises and encourages clients to seek
professional medical diagnosis and advice regarding any illness or symptoms they are
experiencing, and to inform their physician of any and all supplements they are taking. This in
turn will aid in the process of a holistic herbal consultation. With this in mind, we ask
all clients to bring with them to their consultation any test results, written diagnoses, or
other medical information regarding their condition.
By signing below, you are acknowledging that we make no claims to be licensed
physicians, or to diagnose or treat illness, or to prescribe medications. Furthermore,
you are acknowledging that you will be working with a student or students of
herbalism under the supervision of instructors and/or receiving feedback on their
work.
I,_________________________________________, have read and understand the above statement.
Signature:________________________________________________________
Date:_______________
www.arborvitaeny.com
One Union Square West, Suite 309 New York, NY 10003
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