New Client Intake Form – Stascha Stahl

Please take time to read and complete the following:

Fill out the intake form below. Please fill out only what you are comfortable with. These questions are designed for me to become familiar with your health history, constitution, and any thing you are hoping to accomplish in our visit. For example, I will ask about food intake and digestion or stress levels because they are both vital parts of interconnected holistic health. Many patients find filling out this intake form is therapeutic for them and clarifies goals/history/etc. To reiterate, if there is any question you don’t want to answer, that is totally okay.
Please note any place you have a question and we will be sure to address it. We will go over this form together during the consultation.
Please bring all bottles of pharmaceutical and over-the-counter medicines, as well as supplements and tinctures that you take on a regular basis.
You are encouraged to bring along any medical records, blood tests, or other pertinent information you think may be helpful.
Client confidentiality will be observed under all circumstances.
If you discover that you are pregnant during the course of our work together, please discontinue all herbal supplements until we can discuss whether your recommendations need to be modified
If you have any questions, please contact me at stascha@nullbayherbalist.com

Please take as much space as you may need to answer any of these questions.

Name

Today's Date

Address

Phone #

Preferred contact method

Phone
Email

Gender

E-mail

Date of Birth

Pronouns

What are your primary goals in working with an herbalist?

What other health-related issues do you have/have you had in the past?

Please list any other practitioners you are currently working with (type of pracitioner and name)

Medications currently or previously used (over the counter and prescription). If you are able to bring in the bottles, you can skip this part! For each medication, please list: a) the medication, b) the dosage, c) how long, and d) reason for taking.

Supplements/Vitamins/Herbs currently or previously used. If you are able to bring in the bottles, you can skip this part. For each medication, please list: a) the supplement/vitamin/herb, b) the dosage, c) how long, and d) reason for taking.

Occupation

How long?

Previous Occupations

Are you allergic or sensitive to any substance (medications, pollens)?

Have you had any surgeries? If so, for what reasons? Please describe any complications:

Height

Does your weight fluctuate?

Typical bedtime

Typical hours asleep

Do you feel rested upon waking?

How often do you consume dairy products?

Eggs

Alcohol

Fish

Nuts

Tobacco

Vegetables

Fruits

Bakery goods

Water

Beans

Soy products

Butter

Fried foods

Chicken, turkey

Seeds

Coffee

Red meat

Greens (kale, collards, etc)

Chips/crackers

How often do you cook?

How many meals do you eat per day?

Snacks?

Do you have foods that you are allergic or sensitive to?

Do you follow or have you ever followed a restricted diet? Which one(s)?

What foods do you crave?

What is a typical day of food for you? Or, if there is not a typical day of food, what did you eat yesterday?

If you menstruate, what are your periods like? Feelings/emotions before:

Sensations before:

Pain/cramping before:

If you menstruate, what are your periods like? Feelings/emotions during:

Sensations during:

Pain/cramping during:

If you menstruate, what are your periods like? Feelings/emotions after:

Sensations after:

Pain/cramping after:

How long is your menstrual cycle from first blood to next blood?

How many days do you bleed?

How many days do you spot (if any)?

Is there an excess of stress in your life?

Do you have any tools or practices that aid you in times of stress? If so, what helps?

Please list any major events in the last ten years of your life (or further back if it seems significant) and rough dates they occurred. Include events such as births, deaths, marriages, divorces, accidents, moves, job changes, illnesses and anything else you feel greatly impacted your life.

What is your desired goal for your clinic visit? What would success with herbs look like for you?

Message

Thank you so much for filling out this intake form!