Sacred Plant Traditions, LLC
PO Box 1313
Charlottesville, VA 22902
434.295.3820
Personal Health Profile
Name:
________________________________________
Date: _________________
Address:
_________________________________________________________________________
_________________________________________________________________________
Phone #’s
Date of Birth:
Home: _______________________
Work: ____________________________________
Fax:
E-mail: ___________________________________
_______________________
________________ Age: _________
Weight: _____ Height: _____ Blood Type: _______
Occupation: ___________________________________________________________________________
Relationship Status:
__________Partner’s Name_______________Partner’s Occupation: ___________
Names & ages of Children:
_____________________________________________________________
______________________________________________________________________________________
Present Health Concerns
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Physician’s Diagnosis:____________________________________________________________________
Physician’s Treatment:____________________________________________________________________
Other practitioner’s response:
_____________________________________________________________
Do you have any allergies? To what? _______________________________________________________
Please list any food allergies
_____________________________________________________________
Please list any allergies to any medications:
________________________________________________
Please list any medications taken regularly, either prescribed, recreational or over-the-counter:
______________________________________________________________________________________
Please list any vitamins, minerals, or herbal supplements taken regularly: ____________________________
______________________________________________________________________________________
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Body System Health Profile
Please check any item listed below, rating it as follows:
1 = sometimes
2 = often
3 = major concern
Please leave blank if not applicable
Circulatory
Respiratory
___ High Blood Pressure
___ Low Blood Pressure
___ Palpitations
___ High cholesterol
___ Triglycerides
___ Varicose veins
___ Spider veins
___ Cold hands & feet
___ Poor circulation
___ Pain in chest
___ Previous heart stroke
___ Swelling in ankles/joints
___ Other: _________________________________
___ Allergies
___ Asthma
___ Sinusitis
___ Post nasal drip
___ Sore throat
___ Lung congestion
___ Difficulty breathing
___ Cough
___ History of Tuberculosis
___ Recurrent influenza
___ Cold
___ Other: ________________________________
Eyes, Ears, Nose & Throat
Digestive
___ Eye pain, wet/dry
___ Failing vision
___ Ear aches
___ Hearing loss
___ Ringing in the ears/Tinnitus
___ Hay fever
___ Tonsils
___ Other: _________________________________
___ Boils
___ Acne
___ Eczema
___ Psoriasis
___ Bruise Easily
___ Herpes simplex
___ Slow wound healing
___ Other: _________________________________
___ Mouth ulcers
___ Halitosis - bad breath
___ Hiatal hernia
___ Bloating
___ History of Hepatitis
___ Gall Stones
___ Hypoglycemia (Low Blood Sugar)
___ Indigestion
___ Ulcers
___ Constipation
___ Diarrhea
___ Irritable Bowel Syndrome
___ Polyps
___ Hemorrhoids
___ Bleeding from Anus
___ Flatulence
___ Have you traveled abroad often?
List where: __________________________
___________________________________
___ Other: ________________________________
Urinary
Musculo/skeletal
Skin
___ Bladder infections (cystitis)
___ Kidney stones
___ Water retention /swelling of ankles/legs
___ Incontinence
___ Painful urination
___ Excessive urination
___ Lower back pain
___ Dark circles under the eyes
___ Gout
___ Other ________________________
___ Stiffness
___ Bursitis
___ Torn ligaments
___ Backache, upper/lower
___ Broken bones: List: ______________________
___ Arthritis
___ Mobility restriction
___ Gout
___ Sprains
___ Other ________________________
2
Reproductive (Women)
___ Pregnancies, Date: ________________Miscarriage Date: _____________Abortion Date: __________
___ Contraceptive use: List type(s) & how long: _______________________________________________
___ Sexually transmitted disease, List Type if known: ________________________________
___ Hysterectomy, Date: ______________ Reason: _________________________________________
___ Uterine fibroids
___ Ovarian cysts
___ Genital Herpes
___ Endometriosis
___ Cervical dysplasia
___ Vaginal Infection
___ Painful intercourse
___ Breast pain
___ Anemia
___ Breast lump
___ Vaginal itching/discharge
___ Pelvic Inflammatory Disease
___ Infertility
Menstruating Women
Menopausal Women
___ Irregular menstrual cycles
___ Heavy menstrual bleeding
___ Painful menstrual cramps
___ Bleeding between cycles
___ Absence of menstrual cycles
___ Dramatic mood swings around menstrual cycle
___ Lack of sex drive
___ Other: _________________________________
___ Hot flashes
___ Dramatic mood swings
___ Dry vaginal lining
___ Osteoporosis
___ Vaginal bleeding
___ Estrogen Replacement Therapy
___ Lack of sex drive
___ Other: ________________________________
Reproductive (Men)
___ Impotence
___ Sexually transmitted disease
List Type if known: ______________________
___ Prostatitis
___ Difficulty with urination
___ Benign Prostatic Enlargement
___ Premature Ejaculation
___ Lack of sex drive
___ Low sperm count
___ Low sperm motility
___ Other:________________________________
Endocrine Glands
Lymphatic
___ Pituitary
___ Pineal
___ Thyroid
___ Hypothyroid
___ Hyperthyroid
___ Pancreas
___ Diabetes (Please indicate Type I or Type II)
___ Hypoglycemia
___ Other: _________________________________
___ Congestion
___ Swollen glands
___ Infection
___ Drainage
___ Other: ________________________________
Nervous System
Immune System
___ Anxiety
___ Auto-immune disease
___ Irritability
___ Chronic Fatigue Syndrome
___ Stress
___ Fibromyalgia
___ Headaches
___ Neuralgia
___ Migraines
___ Frequent colds
___ Insomnia
___ Vaccinations
___ Depression
___ Chronic Fatigue Syndrome
___ Attention deficit
___ Other: ________________________________
___ Hyperactivity
___ Mental sluggishness
___ Irritation to strong light
___ Shingles ___ Other: _________________________________
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Past Medical History
Please list any operations you have had with date, including appendectomy, tonsillectomy, etc:
______________________________________________________________________________________
______________________________________________________________________________________
Please list any major injuries/accidents, including date: __________________________________________
______________________________________________________________________________________
Please list any traumatic experiences not treated medically (divorce, loss of lover, loss of job, death of loved
one, etc) _______________________________________________________________________________
______________________________________________________________________________________
Family Medical History
Maternal Medical History: _________________________________________________________________
______________________________________________________________________________________
Paternal Medical History: __________________________________________________________________
______________________________________________________________________________________
Sibling Medical History: ___________________________________________________________________
______________________________________________________________________________________
Are you or any family members in a recovery program? If yes, which one? ___________________________
______________________________________________________________________________________
Common Physical Activities
Please list ______________________________________________________________________________
______________________________________________________________________________________
Diet
Please write a diary of your meals on a typical day:
Breakfast:_______________________________________________________________________
Lunch:__________________________________________________________________________
Dinner: _________________________________________________________________________
Comments:_____________________________________________________________________________
Food Category
Never
Food Use Frequency
Sometimes
Comments
Often
Meat (Beef, Pork)
Dairy (Milk, cheese, yogurt)
Fried Foods
Sugar
Alcohol
Coffee/ Caffeine
Soda/ Diet Soda
Water
Tobacco
And finally, please take a moment before finishing this & tell us your most immediate need or goal at this
time.__________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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Thank you for taking an active role in the Sacred Traditions Center for Plant Studies’
Student Clinic. We appreciate your participation.
Please read the statements on the following page and sign if you are in
agreement. We apologize for such a strong release waiver, we are just
following counsel’s advice.
Staff Use Only ---Please do not write below these lines
Tongue
Body: ____________________________
Coat: ____________________________
Features:_________________________
Constitution
Type
Kapha
Pita
Vata
Sys
Action
GI
Mus S
Ner S
Relaxation
Doing
Thinking
Evaluation
Pulse
Pos
Left
Right
I
Sm Int
Heart
Lungs
Colon
II
Gall
Liver
Spleen
Stomach
III
Bladder
Kid yin
Heart Protector
Triple Heater
Notes: ___________________________
_________________________________
_________________________________
Blood Pressure: ____________________
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Sacred Plant Traditions, LLC
PO Box 1313
Charlottesville, VA 22902
ASSUMPTION OF RISK, RELEASE, COVENANT NOT TO SUE AND AGREEMENT TO
HOLD HARMLESS
The undersigned hereby accepts and assumes all risk and liability associated with my
taking the formula or tincture provided to me by my attending herbalist and Sacred Plant
Traditions, LLC and its Clinic.
The undersigned hereby assumes any risk of an injury to myself or others in my care. The
undersigned hereby releases, waives and discharges the attending herbalist and Sacred
Plant Traditions (SPT) from any and all liability from any loss or damage, and claims or
damages resulting therefrom, on account of injury to persons or property, even injury
resulting in death, whether caused by the attending herbalist and Sacred Plant
Traditions,LLC negligence or otherwise.
The undersigned will indemnify and hold harmless the attending herbalist and Sacred Plant
Traditions, LLC from any loss, liability, damage, expense or cost, whether caused by the
attending herbalist and SPT,LLC’ negligence or otherwise, and whether claimed by or
through the undersigned or others, including costs and attorney’s fees incurred or suffered
by reason of any claims, demands, actions, or suits which may be filed or claimed against
the attending herbalist and Sacred Plant Traditions, LLC. The undersigned covenants not
to sue the attending herbalist and Sacred Plant Traditions, LLC and will not individually, or
for others, or on behalf of minors, bring or prosecute, or in any way aid in the institution or
prosecution of any claim or suit against the attending herbalist and/or Sacred Plant
Traditions, LLC
References to the undersigned shall also include and obligate the undersigned’s spouse,
family, children, guests, invitees, heirs, and assigns, and all persons claiming by or through
the undersigned. References to Sacred Plant Traditions, LLC shall benefit Sacred Plant
Traditions, LLC, and the Sacred Plant Traditions Clinic, its lessor, officers, employees,
agents, successors and assigns.
Signed this _______ day of ________________________________, 200__.
___________________________________
Signature
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