Client Intake Form
This intake form helps me to understand the totality of the symptoms that you are experiencing. Rather than the allopathic approach of treating only the symptom, I use this information to create a whole picture of what could potentially be the cause of the symptom so that we can work together to resolve the issue holistically and I can compound a curative and balancing remedy specifically for your constitution. After you complete the intake form and I have reviewed it, we will meet for your consultation in which I will ask you questions for further clarification and gather any additional information I may need to create your wellness plan.  
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Are you a new or existing client? *
Have you received a custom compound from me in the past? *
Your name *
Phone number *
E-mail *
Preferred contact method *
Required
What is your birthday? *
MM
/
DD
/
YYYY
What is your age? *
What is your weight? *
What is your height? *
In your own words, describe the condition that you are hoping to remedy. Please be as thorough and detailed as possible. *
When did this particular issue arise? *
What was going on in your life around that time? Any stressful/exciting events or changes to your diet, lifestyle, work, family, or social situations? *
How was your stress level at that time? *
Not stressed
Super stressed
How is your stress level now? *
Not stressed
Super stressed
Did you experience ANY traumas, accidents, injuries, or surgeries during this time period? *
If yes or maybe, please explain:
Did you begin taking any herbs, supplements, over-the-counter or prescription drugs at that time? *
Are you currently taking any herbs, supplements, over-the-counter or prescription drugs right now? *
Have you noticed anything that makes your specific symptom/condition better? This could be foods, times of day/year/season, exercise, supplements, herbs, drugs, or anything else. *
Have you noticed anything that makes it worse? *
Is there anything you can think of that you feel like you need to do or stop doing in order to make your condition improve? *
Please describe to me in detail the nature of your condition and the sensations/locations associated with it (ex: burning in throat or dull pain in lower abdomen, etc.). This helps me understand the specific tissues affected. *
How do you feel physically AND emotionally when your symptoms arise? *
Does your health concern impact other areas of your life? Is it affecting your sleep, libido, relationships, hobbies, work, exercise, social situations, goals, etc.? *
If you're in pain or discomfort, is the sensation moving into or affecting other regions of your body from the main area of concern? *
Are there any other symptoms that you're experiencing or areas of concern that may or may not be related to what's going on? Even if you think something isn't connected to your main area of concern, it could be, so please list out any other concerns or experiences you have been having. *
How would you rate the severity of your symptoms? *
Not Severe
Most Severe
Is this a consistent score or does it fluctuate? *
What do you think you could adjust about your lifestyle right now to make this score better? *
If it fluctuates, what number would you give it when it's at its worst?
What number would you give it at its best?
Have you noticed any patterns in relation to your symptoms? For example, time of day, seasonal changes, weather changes, hormonal changes, etc. *
How would you classify the frequency of your condition? 1 being rarely, 2 being occasionally, 3 being frequently, and 4 being constantly. *
Rarely
Constantly
How many times per day, week, or month does this symptom arise? *
Do you have any known allergies? *
How would you rate your energy levels? *
Sluggish
Energetic
Do you experience cold hands and/or feet? *
If yes, is the change in temperature gradual as you from your hands/feet up your arms/legs? Or is it a sudden and stark temperature change?
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How would you describe your bowel movements? *
How regular are your bowel movements? *
How would you describe your skin (your face, scalp, and body)? *
Are you acne prone and/or experience body acne? Choose all that apply. *
Required
Do you currently experience any skin conditions? (Dandruff, dermatitis, psoriasis,  eczema, acne, rosacea, hives, vitiligo, Raynaud's syndrome, etc.) *
Have you had any surgeries or organ removals in your life? *
If yes, please explain:
Do you have varicose veins or spider veins? *
Do you bloat, have indigestion, burp, or experience flatulence after you eat? *
Is there anything else that you think that I should know? *
Do you have any preferences in how you'd like your herbs administered? (Ex: no alcohol extractions, don't have time to make teas, dislike the taste of a particular herb, etc.) *
Thanks so much for taking the time to fill out the intake form. We will discuss this further at your consultation and I look forward to helping you create a wellness plan!
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