Herbal Medicine Consultation Form

Gather a full health picture before a herbal medicine appointment. Clients share contact details, current concerns, allergies, medication, existing diagnoses, family background, daily habits and the outcome they hope for. The practitioner arrives at the session already knowing what to explore.

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Full Name

Nombre

Apellido

Email Address

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Date of Birth

Occupation

What are your primary health concerns? (Select all that apply)

Digestion Sleep Stress and anxiety Energy and fatigue Immune support Pain and inflammation Skin Hormonal balance

Please describe your health concerns in detail:

Have you previously used herbal medicine?

Yes No

If yes, please specify which herbs or treatments you have used:

Do you have any allergies or sensitivities? (e.g. foods, medication, herbs)

Are you currently taking any medication or supplements?

Have you been diagnosed with any medical conditions?

Do you have a family history of any medical conditions?

What are your lifestyle habits? (Select all that apply)

Regular exercise Balanced diet Smoking Alcohol consumption High-stress work Poor sleep Meditation or yoga

What are your goals for this consultation?

Preferred Method of Consultation

In person Video call Phone call Chat

Additional Comments or Questions

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