Terri Lundquist
Herbalist
Email: info@tvhmillerton.com
Phone: 518-592-1600
The Village Herbalist
28 Main Street
Millerton, NY 12546
This detailed intake form has many questions that may or may not pertain to the reason for your visit. Its purpose is to identify any undiagnosed conditions or links you may be unaware of; and to help me better formulate the right approach for your individual needs. Please feel free to answer only the questions you feel are important toward your health concerns. Any questions you would rather discuss in person can be marked for future discussion. All of the information herein is strictly confidential and will be treated with care and respect.
Name __________________________________________ Today’s date _________________
Primary Address ______________________________________________________________
City _____________________________________ State ________________
Phone: Home ____________________________ Other __________________________
Email __________________________________________
Date of birth ___________________ Age ___________ Gender___________________
Height ___________________________ Weight ____________________________
Relationship status__________________ # of Children _________ Pets ___________
Occupation ________________________________ Enjoy your work? ___________________
Main Reason for visit (diagnoses, main complaints and symptoms)
Other health issues
Hobbies, skills, interests, favorite pastimes
How many hours per week do you spend doing the following activities?
____Working ____Sitting
____TV
____Playing
____With friends
____Exercising
____With family
Exercise-what type of daily, weekly or monthly exercise do you practice, if any?
Page 1

Terri Lundquist
Herbalist
Email: info@tvhmillerton.com
The Village Herbalist
28 Main Street
Millerton, NY 12546
Phone: 518-592-1600
Practitioners
Please list any health care practitioners you have previously seen or are currently under the care of,
(Chiropractor, counseler, naturopath, gynecologist, physical therapist, psychiatrist or psychologist, medical doctor, spiritual counselor, etc.)
Current: ______________________________________________________________________
Past: _________________________________________________________________________
Western medical diagnosis known (please include any significant lab reports if possible)
Current medications and treatments Previous medications and treatments
Health History
Please check any of the below symptoms or diseases you have experienced. If you can, please mark ‘P’ for previous condition, ‘C’ for current and ‘O’ for occasionally.
____ADD/ADHD
____AIDS
____Alcoholism
____Allergies
____Anemia
____Anxiety
____Arthritis
____Asthma
____Bloating
____Cancer
____Chemical
sensitivities
____Chronic fatigue
____Common cold
____Constipation
____Diabetes
____Diarrhea
____Dizziness
____Drug abuse
____ Environmental
sensitivities
____Epilepsy
____Epstein-Barr
virus
____Excess stress
____Eyesight
problems
____Fatigue
____Gynecological
problems
____Headaches
____Hearing
problems
____Heart disease
____Hepatitis A
____Hepatitis B
____Hepatitis C
____High blood
pressure
____HIV
____Hyperglycemia
____Hypoglycemia
____Immune
disorders
____Injuries
____Low blood
pressure
____Male health
problems
____Memory loss
____Menopause
problems
____Menstrual
irregularities
____Numbness
____Painful joints
____Rashes
____Recreational
drug use
____Respiratory
problems
____Seizures
____Shingles
____Shortness of
breath
____Sleep problems
____Sore throats
____Stiffness
____Stomach aches
____Swelling
____Tobacco use
____Tumors
____Urinary tract
infections
Other___________
________________
Page 2

Terri Lundquist
Herbalist
Email: info@tvhmillerton.com
Phone: 518-592-1600
Immune System
The Village Herbalist
28 Main Street
Millerton, NY 12546
Mark any of the conditions below that pertain to you.
____Allergies ____Graves disease
____Autoimmune
disorder
____Heal slowly
____Infections
____Catch
everything
____Chronic fatigue
____Low grade
fever
____Lupus (SLE)
____Mononucleosis
____Rheumatoid
arthritis
_____ Sick often
_____ Sore throats
____Swollen lymph glands
Other___________
________________
Do you have any concerns about your immune system?
How many times a year do you get sick?
Skin
Mark any of the conditions below that pertain to you. Use ‘P’ for past problem and ‘C’ for current.
____Acne ____Eczema/ ____Oily hair ____Sensitive to
____Boils psoriasis ____Oily skin chemicals
____Bruise easily
____Dry hair
____Dry skin
____Hair loss
____Impetigo
____Itchy
____Moles
____Pimples
____Rashes
____Scars
____Slow to heal
____Varicose veins
Other___________
________________
Energy levels
Are you satisfied with your energy levels, please describe?
When is the high point and low point of your daily energy levels?
Have your energy levels changed markedly at any point recently or in your past? What preceded the change?
Hospitalization
Name any circumstances in which you were hospitalized and why (list approximate date and duration of stay)
What was your treatment, were there any follow-ups?
Page 3

Terri Lundquist
Herbalist
Email: info@tvhmillerton.com
The Village Herbalist
28 Main Street
Millerton, NY 12546
Phone: 518-592-1600
Please list any surgeries you’ve had along with approximate dates and reasons for them (appendix, wisdom teeth, tonsils, etc.).
Injuries
What injuries have you had (sprains, tears, muscle injuries, broken bones)?
What therapies and/or drugs did you take for them?
Have you ever been in an automobile or other serious accident?
Family History
If you are adopted, do you know any of your birth family’s medical history?
Has anyone in your immediate family had any of the following
____Alcohol abuse ____Heart disease ____Diabetes Type I
____Cancer
____Drug abuse
____High blood pressure
____Low blood pressure
____Diabetes Type II
Other__________
Is there anything significant about your family medical history that you would like to talk about?
Drug history
Please list any current medical or recreational drugs you are using; include any past drug use that may be significant.
Allergies
Do you have any allergies, what are they?
Which medicines (including herbal) have you taken for them?
When and where are your allergies least and most troublesome?
Do you have allergic reactions to any drugs or herbal medicines?
What has most helped your allergies?
Page 4

Terri Lundquist
Herbalist
Email: info@tvhmillerton.com
Phone: 518-592-1600
Diet
Please fill in the below chart using the following scale
D – Daily; W– Weekly; O – Occasionally; leave it blank if you do not consume it
____Alcohol ____Eggs ____Juice
____Baked goods ____Fast food ____Milk
____Beef
____Beer
____Black tea
____Bread
____Canned foods
____Cheese
____Chicken
____Coffee
____Eat out
____Fermented
foods
____Fish
____Fried foods
____Frozen foods
____Fruit
____Grains
____Green tea
____Herbal tea
____Nut butters
____Nuts/seeds
____Organic foods
____Pork
____Potato chips
____Refined flour
____Refined sugar
____Salt (table or
sea salt?)
The Village Herbalist
28 Main Street
Millerton, NY 12546
____Seaweed
____Skip meals
____Soda
____Sweets
____Vegetables
cooked
____Vegetables raw
____Water
____Wine
Special diets; current and/or previous (kosher, vegetarian, raw food, etc.):
Digestion
Please use ‘P’ for previously, ‘C’ for currently, ‘O’ for occasionally.
____Abdominal ____Diarrhea ____Hemorrhoids
pain
____Anorexia
____Diverticulitis
____Dysentery
____Indigestion
____Irritable bowel
nervosa
____Belching
____Bloating
____Bulimia
____Changes in
bowel habits
____Eating
disorders
____Flatulence
____Food
unappetizing
____Gallstones
syndrome
____Large appetite
____Liver problems
____Low appetite
____Nausea
____Pain after
____Stomach aches
____Sudden weight
change
____Ulcer
____Ulcerative
colitis
____Vomiting
Other___________
________________
____Crohn’s disease
____Constipation
____Giardia
____Heartburn
eating
____Parasites
What are your favorite and least favorite foods? (sweets, breads, meat, veggies, salads, etc.)
What did you have for breakfast, lunch and dinner yesterday and today? (continue on back if necessary)
Yesterday Today
Breakfast
Lunch
Dinner
Page 5

Terri Lundquist
Herbalist
Email: info@tvhmillerton.com
Phone: 518-592-1600
Body Temperature
Please write ‘H’ for Hot or warm and ‘C’ for Cold, if applicable to these body areas
The Village Herbalist
28 Main Street
Millerton, NY 12546
____General body
____Arms
____Fingers
____Legs
____Chest
____Stomach
____Hands
____Palms
____Feet
____Head
Other__________
Is there a part of the day when you are warmest and coldest?
Emotional
Use a scale of 1 (rare) to 5 (very common) on the below conditions that are pertinent to you
____Lethargic
____Manic
____Nervous
____Sad
____Worry
Other____________
____Angry
____Anxious
____Attentive
____Bi-polar
____Calm
____Content
____Depressed
____Dreamy
____Energized
____Enthusiastic
____Fearful
____Grumpy
____Happy
____Inspired
____Joyful
____Loving
What do you like most about yourself?
What do you like least about yourself?
Memory
How is your long-term and short-term memory?
Has your memory changed noticeably in the past few years?
Ears
Have you previously had ‘P’ or currently have ‘C’, or never had ‘N’
____Ear infections
____Earaches
____Hearing loss
____Overly sensitive
____Tinnitus/Ringing
____Wax build-up
How is your hearing, has it changed in the past years?
Other____________
Page 6

Terri Lundquist
Herbalist
Email: info@tvhmillerton.com
The Village Herbalist
28 Main Street
Millerton, NY 12546
Phone: 518-592-1600
Mouth & Throat
Please check any that are pertinent; and indicate ‘P’ for previous or ‘C’ for current conditions
____Bad breath
____Cavities
____Constant dryness
____Difficultly
swallowing
____Grind teeth
____Lip sores
____Loose teeth
____Mouth sores
____Oral herpes
____Excess saliva ____Painful/tight jaw
Headaches
Do you ever have problem headaches, how often. How long have you had them?
____Sore/bleeding gums
____Sore throats
____Swollen glands
____Swollen tongue
Other____________
Location/type of headaches
____After eating
____Afternoon
____Around eyes
____Around
temples
____Aversion to
stimuli
____Back of head
____Band around
head
____Before eating
____Chronic
____Cluster
____Constant
____Dull
____Evening
____Front of head
____Left side
____Migraine
Do you know what triggers them?
Are they seasonal? If so, which season?
Other symptoms associated with the headache (i.e., stomach pain, vomiting)
Are they more or less often than in the past?
Does the severity or intensity vary from episode to episode?
What medicines and treatments have you tried, which were most successful?
Urinary Tract
Please mark ‘P’ for previous, ‘C’ for current, and ‘O’ for occasionally for any of the below conditions
____Morning
____Night
____Pounding
____Pre-menses
____Right side
Other_______
____Bloating
____Blood in urine
____Burning urination
____Frequent urge to
urinate
____Kidney/bladder stones
____Kidney pain
____Leaking
____Lower back pain
____Strong smelling urine
____Thirsty all the time
____Urinary tract
infections
____Water retention
Other____________
Page 7

Terri Lundquist
Herbalist
Email: info@tvhmillerton.com
Phone: 518-592-1600
Approximately how many times a day do you urinate?
Do you wake up at night to urinate, how many times?
Is it ever difficult to urinate?
Does your need to urinate ever seem urgent?
Have you had urinary tract infections? How often? How did you treat them?
After urinating, does it ever feel like you still have urine in your bladder?
Bowel Movements
The Village Herbalist
28 Main Street
Millerton, NY 12546
How many times a week do you have a bowel movement?
Is it ever difficult? Do you strain?
Do your stools tend toward loose (soft) or hard?
Are you ever constipated, how often?
Do you ever have diarrhea (very loose stools)?
Is your need to defecate urgent?
Does it ever hurt to defecate?
Are your stools often very strong smelling?
Other bowel problems or symptoms?
Reproductive
Are you sexually active? What form of birth control do you use, if any?
Have you had any of the following? Write ‘P’ for previously ‘C’ for currently, ‘S’ if you suspect you may have it.
____AIDS ____Genital warts ____Syphilis
____Candida
____Chlamydia
____Gonorrhea
____HIV
____Urethritis
Other__________
____Crabs/lice ____Human Papilloma Virus
Please list any herbs or drugs you have used as treatment for the above
Page 8

Terri Lundquist
Herbalist
Email: info@tvhmillerton.com
The Village Herbalist
28 Main Street
Millerton, NY 12546
Phone: 518-592-1600
Reproductive – Male
Have you had any of the following symptoms or conditions? Use ‘P’ for previously and ‘C’ for currently.
____Benign Prostatic
Hyperplasia (BPH)
____Blood in semen
____Blood in urine
____Difficulty getting
urine flowing
____Excessive sexual
thoughts
____Frequent urination
____Impotence
____Interrupted flow of
urine
____Painful to urinate
____Penis pain
____Prostate pain
____Testicle pain
____VD exposure
Other____________
____Dribbling
____Erectile dysfunction
____Libido low
____Painful ejaculation
_________________
Do you get up at night to urinate, how often?
Does your prostate region ever hurt? If yes, is pain dull, constant, throbbing or sharp?
Is it ever painful to urinate (describe the pain)?
Does the urge to urinate interfere with your daily activities?
Do you have any problems getting and/or maintaining an erection?
Do you have any health concerns about your sexuality or vitality?
Reproductive – Female
Use ‘P’ for past condition, ‘C’ for current, ‘S’ for unsure or ‘?’ for any questions.
General
____Breast pain
____Cysts
____Endometriosis
____Fibroids
____Painful intercourse
____Pelvic inflammatory
disease (PID)
____STDs
____Vaginal discharge
____Vaginal dryness
____Vaginal infection
____Vaginitis
____Infertility
____Miscarriage
____Tumors
____Unusual PAP
____VD exposure
Other_____________
Menstrual Cycle: Age at onset _____________, date of last gynecological exam ____________________.
Average number of days bleeding _________________.
Approximately how many days from the start of one period to the start of the next ___________.
____Acne ____Bloating (hands, ____Irregular cycle
____Cramps stomach) ____Painful menses
____Bleeding between cycles
____Mood swings
____Bloating (feet, hands,
ankles)
Other_________________
Page 9

Terri Lundquist
Herbalist
Email: info@tvhmillerton.com
Phone: 518-592-1600
Menstrual Blood Color
____Bright red
Flow
____Red
____Dark colored
____Clots
Perimenopause and Menopause
Are you currently experiencing any of the following?
____Scanty flow
____Slow flow
____Heavy flow
____Profuse flow
The Village Herbalist
28 Main Street
Millerton, NY 12546
____Dry vaginal mucosa
____Hormone replacement
therapy
Contraception Method
____Hot flashes
____Mood swings
____Night sweats
Children
____Osteoporosis
Other____________
Grandchildren
____Birth control pills
____Birth control patch
____IUD
______ Boys
Ages_______________
______ Girls
______ Boys
______ Girls
____Diaphragm
Other______________
Ages_______________
# of pregnancies _____, adoptions _____, miscarriages______
Sleep Patterns
Please mark the conditions pertinent to you.
____Fall asleep fast
____Sleep through the night
____Hard to fall asleep,
but stay asleep
____Hard to fall and stay
asleep
____Wake often
____Wake up to urinate
____Hard to wake up
Other___________________
________________________
Dreams (circle those that apply): never, occasionally, frequent, active, lucid, anxious, nightmares, probing, pleasant, interesting, scary, other?
Generally, how many hours of sleep do you need to feel rested?
An average do you feel rested when you wake in the morning?
Cardiovascular Health
Please check the questions pertinent to your health
____Angina
____Arm pain/jaw pain
____Arrythmias
(irregular heartbeat)
____Arteriosclerosis
____Bruise easily
____Bleed easily
____Capillary fragility
____Cardiac arrest
____Chest pains
____Congenital
deformities
____Congestive heart
failure
____Deep leg pain
____Edema
____Cold hands & feet
Page 10

Terri Lundquist
Herbalist
Email: info@tvhmillerton.com
Phone: 518-592-1600
____Fast heart beat
(tachycardia)
____Slow heart beat
(bradycardia)
____Heart attack
(myocardial infarction)
____Mitral valve prolapse
____Palpitation
The Village Herbalist
28 Main Street
Millerton, NY 12546
____Heart flutter
____Heart irregularities
____Poor circulation
Other____________
____High blood pressure
____Low blood pressure
____Stroke
____Varicose veins
Cholesterol (if know, VLDL, LDL, HDL and total cholesterol)
Does your family have a history of heart conditions, please explain.
When your blood pressure is checked, is it usually high or low? Do you remember any readings over the last few years?
What drugs, herbal medicines or other treatments have you used for your heart?
Nervous System and Stress
Please mark any conditions that are, or were previously, pertinent to you. Circle anything you would like to discuss further.
____Anxiousness
____Bipolar ____Fluctuating vision ____Panic attacks
____Butterflies in stomach
____Cannot stay asleep
____Constant feeling of
stress
____Diminished taste
____Hard to concentrate
____Involuntary spasms
____Mania
____Memory loss
____Nervousness
____Seasonal affective
disorder
____Sudden mood swings
____Trouble falling asleep
____Twitching
____Depression
____Fear of facing a new day
____Numbness
____Pain – constant
Other________________
Describe your stress levels, what goes wrong with your body when stress levels are elevated?
What do you do to relieve stress (exercise, pray, meditate, walk, read, other)?
Do you have a spiritual path/higher power/belief in nature?
Page 11

Terri Lundquist
Herbalist
Email: info@tvhmillerton.com
Phone: 518-592-1600
Respiratory
Please mark with a ‘P’ for previously a problem, ‘C’ for currently.
The Village Herbalist
28 Main Street
Millerton, NY 12546
____Asthma
____Bronchitis
____Chest pain
____Common cold
____Coughing
____Fluid in lungs
____Hay fever
____Laryngitis
____ Respiratory
inflammation
____Sinus
congestion
____Sinus infection
____Sneezing
____Stuffy nose
____Tight around
lungs
____Trouble
breathing in
____Trouble
breathing out
____Tuberculosis
____Difficulty
smelling
____Flu (influenza)
____Runny nose
____Shortness of
breath
____ Wheezing
Other ____________
__________________
Do you have much congestion, in which season is it worst and best? What helps it?
Mucous- quality and/or color
____Clear
____Green
____Yellow
____Thick/sticky
____Thin/runny
Have you identified foods, environmental factors or situations that worsen your breathing?
What are they?
Cough – check the symptoms which pertain to you
____Persistent
____Regularly
____Wet cough
____Bloody
____Croupy
____Dry cough
____Hacking
____Itchy throat
____Painful
How would you describe the air quality in your home? In your work place?
Are there any other concerns you wish to share?
Page 12