INFORMED CONSENT
We both understand that only a physician (MD) can diagnose, treat, and prescribe medicines for illness or disease. As an herbalist, and not a medical doctor, I neither diagnose nor treat disease but recommend herbs, dietary, lifestyle and other modalities to help the body-mind to achieve optimal physical and emotional well-being. Any mention to named diseases is referenced as a part of the overall assessment and condition of the client.
I understand that 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 make suggestions in lifestyle, diet, and supplementation of herbs and/or vitamins to foster an increased state of balance and health with the intention of optimizing the body's self-healing capabilities.
As appropriate and necessary, 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. This consultation with me is not a substitute for that.
I am disclosing any pharmaceuticals I may be taking and will update Melissa if this changes over the time she is consulting with me.
Please sign below once you have read and understood and agree with the above statement:
Name (print)___________________________________________________
Signature_____________________
(How to add a signature in gmail).
Intake Form
Please provide the following information. Every detail can be a clue to your entire picture, any information you give me is helpful even if you don’t see how it could be.
Everything is confidential.
There is no need to repeat yourself while filling out this form, but do add at the end anything else you can share that hasn‘t been mentioned.
Name Date
Address
Telephone Email
Skype name if applicable
Gender Date of birth
Height and weight Occupation
Marital status Nearest relative
Children (include ages)
Emergency contact (name and phone#)
Primary Care physician (name and phone#)
Rate your commitment to healing on a scale of 1-10:
Gender Date of birth
Height and weight Occupation
Marital status Nearest relative
Children (include ages)
Emergency contact (name and phone#)
Primary Care physician (name and phone#)
Rate your commitment to healing on a scale of 1-10:
Are you okay with a Decoction and/or Infusion as your formula (this is included free with your consultation), or do you prefer a Tablet/Capsule? (If you prefer the latter, I will make recommendations of what you can purchase online).
Please list all medications, including herbs and vitamins you are presently taking, or therapies you are presently undergoing:
Have you ever undergone herbal therapy before?
Do you generally respond well to medical treatments, medicines, therapies, etc.?
PRIMARY COMPLAINT -- (Describe your symptoms to the best of your ability, how you experience the problem):
When did you first notice it?
What circumstances preceded it?
How long has is been occurring?
What do you think is causing it?
When and under what circumstances does it seem to improve/get worse?
Have you seen anyone else for this condition?
If so, when and by whom, and what did you do?
SECONDARY COMPLAINTS --- (List any other symptoms you are experiencing regardless of whether it seems related to your primary complaint):
When did you first notice them?
How long have they been occurring?
When and under what circumstances do they seem to improve/get worse?
Have you seen anyone else for this condition?
If so, when and by whom, and what did you do?
Medical History (List allergies and all past illnesses, injuries and operations):
Medical History of Relatives (Briefly):
Grandparents, Parents, Aunts/Uncles, Siblings, Children
Blood Type?
Ancestry? (What part of the world your parents/grandparents lived):
Current health of parents/siblings?
Check if you have experienced any of the following conditions:
If you have in the past, use a P, if recently use an R, if frequently also include an F.
low, soft voice
hoarse voice
any infectious diseases? if so what, when?
prolapse of uterus, bladder, kidneys, stomach, anus, vagina - describe:
bearing down sensation in abdomen
sensation of tightness or distention around ribs or chest
feelings of heaviness, pressure, or oppression - where?
lump in the throat
hard, relatively immobile masses, where?
soft, palpable lumps, where?
cysts and fibroids
lumps in neck, groin, breast, or flank - where?
swelling of organs, describe:
hemorrhages
bloody nose
hemorrhoids
large loss of bright red blood
delirium
burning sensations, where?
mouth and tongue ulcers
stuffy or runny nose w/ clear-watery mucus
stuffy or runny nose w/ yellow mucus
chills, describe:
fever, describe:
swollen tonsils
exhausted spirit
hypochondria
difficulty in swallowing
deafness
tinnitus
tight neck and shoulders
tics
difficult speech
paralysis, where?
contraction of scrotum or shrinking of vagina
falling hair
premature graying of hair
premature aging
brittle bones
weakness of lower back
thin body
desire to have abdomen massaged
HBP
LBP
Hypoglycemia
Low Body Temp.
Epilepsy
Gallstones
Heart Problems
Kidney Stones
Hepatitis (specify A, B, C & dates)
Carcinoma, describe:
Allergies
Sinus infections
Enlarged Lymph nodes
Frequent colds and flus
Mononucleosis
Lyme
Thyroid Problems, describe:
Glandular problems, describe:
TB
Genital sores
Other, describe:
For people with vaginas:
birth control? if so, what kind and how long?
If menstruating:
What is the length of your menstrual cycle?
What is the length of your menses itself?
Do you ever experience PMS tension, irritability?
Cramping? If so when? Describe.
Clotting, describe? Light flow? Excessive flow? Color?
Is it ever delayed? Is it regular? Do you ever skip a menses?
Details?
Swollen breasts/bloating before menses?
Describe any other discharges………… Do you have itching, dryness? etc.
Details?
Uterine bleeding?
List the dates and years of any children you have birthed and if they were normal delivery:
If menopausal, please list symptoms experienced:
______________________________
For people with penises:
penile discharge:
pain/swelling in testicles?
blood in semen?
genital pain/itching?
nocturnal emissions?
vasectomy?
other?
______________________________
How would you describe your energy level?
High ___________ Low ___________ Up and down ____________
Lethargy? Lassitude with no desire to move? Fatigue?
Physical weakness? Mental listlessness/exhaustion?
Lack of desire to talk?
Desire to lie down?
Full of nervous energy?
Details?
Describe your appetite and digestion.
Do you get gas and/or bloated?
Slow, gurgling, always/never hungry…
Any belching, sour regurgitation, reflux?
Sleepy after eating?
Any major loss of weight or weight gain?
Stomach pain, fullness, stuffiness?
Distention?
Churning or pulsing feeling?
Nausea? Vomiting?
Dryness in mouth or throat?
Bitter, Sweet, or other taste in mouth? Foul breath?
Lack of sensation of taste?
Cold sensations in abdomen?
How would you describe your sex drive?
High __________Low ___________ Up and down ____________Excessive?
Impotence or Frigidity?
Sterility or Infertility?
Premature Ejaculation? Little Sperm?
Details?
How would you describe your elimination?
Bowel Movements: Are they regular (daily) _____________________
Consistency and color: ______________________________
Loose? Dry? Watery? Constipation?
Color: light brown, pale yellow, green, dark, white, red, black?
Do they float or sink? __________ Mucus in the stools? ___________
Do you ever have to strain? Any pain? Any blood?
Undigested food in stools?
Is your stool more like balls or tubes? (If tubes, pencil, thumb, or bigger)
Any smell?
Urine: Is your urinary frequency more than 6x/day or less than 4x/day?
Is it scanty? copious? turbid? Do you have urgency?
Weak stream? Dripping? Incontinence?
Color __________Odor ______________ Other ____________________
Any pain with urination? Any trends toward UTIs? Any burning?
Stopping mid-stream? Sand in urine? Retention?
Dribbling? Difficult urination?
Do you experience night time urination? Number of times/night?
How would you describe your sleep?
Do you dream? Any recurring dreams? Is your sleep disturbed by dreams?
Nocturnal emissions? With or without dreams?
If you have insomnia, do you have trouble falling asleep or staying asleep? Any particular time you seem to be awake? Floating in and out of sleep?
How would you describe your sweating?
Hot flashes? Night sweats? Oily?
Any lack of sweating when appropriate to sweat?
In the afternoon?
How is your memory, concentration, focus?
Mental restlessness?
Confusion?
Uneasiness? Agitation? Fidgety?
How would you describe the stress level in your life? (scale 1 to 10, 10 being worst)
Home
Work
Other
How about headaches or dizziness (even occasionally)?
When?
Where?
Onset and pain type (dull ache, sharp pain, throbbing, pulling, heavy)
Scale of 1-10? Frequency per day/week/month?
What makes it better/worse?
Feelings of heat in face?
Facial pain? Numbness or tingling?
Vertigo?
Anything happening with your mouth, teeth, gums? (now or in the past)
dry tongue? loose teeth? burning sensations? etc.
Any coughing? (When, what type, frequency, productive or non-productive)
Mucus? Color, amount, thickness? Dry? Thin? Watery?
Blood? Itchy throat? Pain?
Breathing:
Wheezing? Asthma?
Difficulty inhaling?
Shallow breathing?
Breathlessness?
Shortness of breath on exertion?
Difficulty breathing when lying down?
Rapid and weak breathing?
Sighing?
Hiccuping?
Sneezing?
Do you ever feel your heart beating?
Describe Skin/Complexion….
Dry, rough, cracked?
Puffy? Swelling?
Red? Flushed?
Eruptions? with fluid? describe.
Pale? Bright or dull? Pasty?
Edema? where?
Superficially red or flushed nose?
Varicose veins?
Purpura?
Bruising?
Jaundice?
Blood spots under skin?
Lips? color? pale, blue, dark red? dry?
Nails? color? yellow, purple? dry? brittle? thick?
Eyes:
blurry vision?
dry?
red?
floaters or black spots?
bad night vision?
eyes looking in different directions?
Any other pain? Where? (scale 1 to 10, 10 being worst)
Since when?
Frequency per day/week/month?
Does the pain feel better/worse if you rub or press it or do you not want it touched?
What makes it better/worse? heat? cold?
Body aches?
Does pain change in severity or location?
Fixed, stabbing, or boring pain?
Sore lower back?
Sore throat? chronic? at night?
With your four limbs:
Weakness?
Difficulty walking?
Feeling of swelling?
Feeling of heaviness?
Muscle aches?
Numbness/tingling?
Joint pain?
Hot/cold/itchy hands & feet?
Tremors?
Twitching/Spasms?
Do you have an unusual susceptibility to heat or cold?
If hot, then morning or afternoon?
Prefer hot or cold (warm cozy room or one with a breeze)?
What temperature do you prefer in terms of climate and foods?
Favorite season?
Do you fear cold?
Have an aversion to heat?
Crave cold foods and drinks?
Desire warm liquids?
Sensations of heat anywhere?
Feelings of coldness? in the back?
What is (are) the predominant emotion(s) you experience? Fearful or anxious? Worry or overthinking? Down or depressed? Frustrated or angry? Sadness or grief? Joyful or content? Irritable?, Agitated?, etc.
Rash behavior?
Uncontrolled laughing or crying?
Moodiness? Mood swings?
Inappropriate anger? Outbursts?
Unhappiness?
Timidity?
Shouting?
Nervous tension?
Subdued, quiet manner?
Lack of courage and initiative?
Jumpy/ easily startled?
Apathy?
Are you content with your life? Home? Work? Social? Other?
What are your strengths?
What are your weaknesses?
Please describe any emotional issues you have in terms of your family, work and social relationships:
Have you had any traumatic life experiences such as rape, incest, abuse, divorce, family deaths, alcoholism, mental illness, other? describe:
What special ambitions or desires do you have?
Do you use alcohol, cigarettes, cola, sugar, coffee, marijuana, cocaine or any other recreational drug? (specify frequency and quantity):
Would you consider yourself to have a sugar, caffeine, nicotine or drug addiction?
Diet
Do you have a strong preference for, or aversion to, any foods or drinks? (specify):
What particular diet or nutritional program do you follow? (Example: vegetarian, macrobiotic, meat & potatoes, etc.)
How would you describe your appetite?
Do you generally cook your own food?
Where do you shop for your food?
Please describe your general diet:
Breakfasts:
Lunches:
Dinners:
Snacks:
Beverages:
Do you have thirst without desire to drink? Or lack of thirst?
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Hobbies and special interests:
Hobbies and special interests:
Physical activities you engage in:
Spiritual activities you engage in:
Mental activities you engage in:
Please add anything you would like to...
Please include a photo of your tongue and any other relevant photos, for instance if you have a skin issue or injury, show me that, etc.
