It all begins with getting to know you. Filling out the Client Intake Form is the crucial first step in the herbalist-client relationship. It allows the herbalist to gather the necessary details and create an individualized plan. By collecting comprehensive information about personal details, health history, lifestyle, current concerns, and emotional well-being, the herbalist can better understand and support their client on their healing journey. Remember, the more details you provide on the intake form, the more accurate and personalized your herbal recommendations will be.

Client Intake Form

Name

First Name

Last Name

Date of Birth

YYYY

Occupation

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Gender

Height / Weight / Age

List all physicians and other healthcare providers/consultants

( Acupuncturist, massage therapist etc.)

Family Medical History

Please list any relevant or major health related issues

Present Health Status

Detail any concerns you may have

Mental & Emotional Health

Please describe your current mental & emotional state

Physical Activity Habits

List your average time sitting, standing, and walking daily. Detail any physical activities you regularly participate in. ( jogging, tennis, yoga, swimming, weight lifting etc.)

Have you had any surgeries?

If so, when & why

Any major injuries / accidents?

Please describe

Any major illness or hospitalizations?

Please detail

Dietary Information

List any food allergies / sensitivities. Any reoccurring food cravings? Detail what & how much you drink on average daily ( how many oz of water, alcohol, tea etc.)

Please journal what you have eaten in the past 48 hours.

Medications & Supplements

It is vitally important that your herbalist is aware of ALL medications & supplements you are taking as some herbs cannot be combined with certain drugs. To help avoid adverse reactions to herbal supplements you may plan to take, please detail the names, dosage, and specify whether each is over the counter or prescription. Include why the medication/supplement is taken.

List all medications, supplements, and herbs to which you have a known allergy

What areas of your health would you like to address?

Statement of Understanding

Only a physician (MD) can diagnose, treat, and prescribe medicines for illness or disease. As an herbalist and not an MD, I neither diagnose nor treat disease. Neither do I prescribe remedies. 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 this healing process is to consider the client as a whole person and to consult with the client concerning changes in lifestyle, diet, and supplementation of herbs and/or vitamins to foster an increased state of balance and health. Thus maximizing the body's self-healing capabilities. I encourage and advise clients to seek professional medical advice regarding any illness or disease they are suffering from. Background health information can aid in the process of a holistic, herbal program and therefore can be shared at the time of the herbal consultation. Any concerns about your health and supplementation with herbs or diet should be done in consultation with your doctor. I respect your privacy. All information shared in this Client Intake Form is strictly confidently.

I AGREE AND UNDERSTAND THE ABOVE STATEMENT

CONFIDENTIALITY NOTICE: This communication and its attachments are confidential and intended for the recipient The Herbalist’s Garden LLC. Information contained in this communication may be subject to the provisions of Privacy Act of 1974 and the Health Insurance Portability and Accountability Act (HIPAA) of 2003. If you received this email in error, please advise the sender immediately and delete the entire message together with all attachments. All unintended recipients are hereby notified that any use, distribution, copying or any other action regarding this email is strictly prohibited.