Forgotten Language Herbs
Confidential Intake
-Walk with an Herb-
How do you feel right now?
Find your healing herbal elixir, tonic or infusion.
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Name:_______________________________________ Email:________________________________________ Date:_______________
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Draw it!
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1) What do you want Herbs to do for you? Big Picture or Specific.
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2) Are you using Herbs now?
____Yes, in Food/ Medicine / Magically/ Spiritually/Aromatherapy/ Tea/ Essential Oils/ Tinctures/ Chinese Herbs/ Recreationally Other:_______________________________________
• _____No. Never have.
Please list your Supplements/ Medications/Herbs
• _____ In the Past. When?:____________________
1. 2. 3.
• What Herbs?:______________________________ • For what Purpose?__________________________
Include what you are using them for:
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Forgotten Language Herbs
Confidential Intake
Energy & Emotions I have been having trouble with: (Circle all that apply)
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Anger Irritability Sensitivity Outbursts Worry Racing or-Repeating Thoughts Poor Memory Hyperactivity Anxiety Difficulty Concentrating Fatigue Sadness Depression Grief Boredom Isolation
Sleep I sleep____hours per night. I have difficulty w/: Vivid Dreams Falling sleep / Staying asleep/Getting up
• What do you do to Relax & Have Fun?
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• What Practice, Image or Story calms & centers you?
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• How’s your Energy? Too little/Enough/Too Much/ Uneven
" " • What’s your favorite Flavor? " " " • What is a Taste you could do without? " " • What’s your favorite Food or Dish? " " 2 of 6
Forgotten Language Herbs " Please circle all of the following symptoms that apply: This / That
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Headaches
Confidential Intake Digestion, Food & Tastes
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My relationship with food:
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No appetite / Excessive Appetite Bingeing/ Cravings
What are they like?
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Recent / Recurrent & Chronic
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Sharp / Dull / Throbbing/Dizziness
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I have trouble with:
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Indigestion /Belching / Bloating / Gurgling
When are they?
Nausea / Vomiting / Ulcers
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Acid regurgitation / Heartburn
Morning / Noon / Evening
Where?
for - Sugar? Salt?/ Other:__________________________
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Hernia / Severe Stomach Pain
After Eating I feel:
Back of Head/ Neck
My Best / Bad / Tired
Forehead/ Temples
Pain
Sides of head/ Top of head Whole head/ Behind
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Eyes
Taste in Mouth:
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Bitter/ Sweet / Sour / Salty / Pungent / Spicy
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Forgotten Language Herbs I like Drinking: Hot drinks / Cold drinks/ with ice
Confidential Intake What kind?____________________ Throat or Chest/ Ears/ Sinus/UTI
# ____Caffeinated drinks/day
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#____ Alcoholic drinks/week
Eyes, Ears & Nose
Problem for you? Caffeine/ AlcoholOther:_______________
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Bowels & Urination Generally: Constipation / Diarrhea/ Alternating / Pain
I experience: Ringing in ears/ Floaters in eyes / Shortness of Breath Allergies: Itchy eyes, ears, nose Sinusitis / Stuffy or drippy nose /
with Pooping
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My poop looks:
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Formed / Loose /Pebble/Bloody
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clogged or constricted throat
Skin & Hair I have difficulty with:
with: Undigested food /Mucus
Eczema / Psoriasis / Acne
Daily Bowel Movements (BM):
Hair:
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1-2 BM per day/ More/ Fewer Urination: Frequent/ Leakage/ Pain I wake to pee_____times/night
Frequent Infections
Itching / Rashes / Hives/ Dry skin, Where?_____________ Premature greying / Hair Loss
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Forgotten Language Herbs Women Last Period:___________________ # of Days flow__________ The blood is: Bright/Dark/Pale with: Clots / Cramping / Bloating
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Before period: Sensitivity/ Breast Tenderness / Discharge Yeast infections
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Men Trouble with Erections Pain in Testicles / Hernia Inflamed Prostate Anything else:___________________
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Sexuality I’m having a difficult time with: Physical Function/ Desire/ Pain Energy/ Partner(s) / Attitude
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Confidential Intake Past Medical History
Please describe any significant injuries, surgeries, major illnesses whether you were hospitalized or not?
" " " " " " " " " " Pregnancy, Children, Birth & Abortion "
Are you presently pregnant or trying to get pregnant? Pregnant/ Trying / Neither Children______ Past Pregnancies_______ Miscarriages ________ Abortions________
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Recreational Drug use
Marijuana: Daily/#____Weekly/ Problem Coke: Daily/#___Weekly/ Problem Other:______________________Daily/Monthly/Problem
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Forgotten Language Herbs
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Have you had any of these conditions? When? PLEASE ADD DATES (ESTIMATES ARE. OK) •Frequent Childhood Illnesses •HIV/ AIDS •Alcoholism •Drug Addiction •Asthma •Birth Trauma (your own) •Cancer •Diabetes •Emphysema •Heart Disease •Hepatitis A/ B /C •Herpes •Lyme Disease •Multiple Sclerosis •Pacemaker •Polio •Rheumatic Fever •Scarlet Fever •Seizures •Tuberculosis •Latex Allergy •Lymph Nodes Removed •Tonsils Removed •Hysterectomy •Anything else removed:______________________
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Confidential Intake
• Is there Anything Else you’d like me to know?
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