Herbal Consultation

First Name

Last Name

Address

Date of Birth

Age

How did you hear about me?

What are your primary health concerns at present?

Describe how long you’ve been experiencing each of them?

What has helped or not helped in the past?

And how you are experiencing them specifically. (For example, if you say “fibromyalgia” please describe your particular symptoms)

List any medications and other substances you take, and how long you’ve been on each one

Have you taken Chinese herbs in the past? Did they help?

You are consistent at taking herbs and supplements?

Do you prefer liquids or pill forms?

Are you pregnant or trying to get pregnant? Are you breastfeeding?

If you are having cycles, how many days apart are your periods? How long do you bleed? is your flow heavy , light or medium? Do you have cramps?

Do you have any mood swings or other cyclical symptoms before, during or after your period? Please describe

Any medical history you’d like me to know about?

Does your child have down time? Time to relax and quiet their minds?

Any surgeries?

Are you allergic or intolerant or needing to avoid any herbs or other ingredients?

Other health factors i should know about?

How’s your sleep? How much do you get?

When do you go to bed, when do you get up?

Do you wake up during the night? If so, what time/how often? can you go back to sleep? Do you have to do anything to get back to sleep?

If you get less than 8 hours, please explain why- insomnia? Kids/animals keeping your up? Schedule/lifestyle?

Do you wake up refreshed or tired or somewhere in between?

Do you move your Body on a regular basis? If so, please describe what you do, how often and how you feel after?

Do you practice any form of mental relaxation? Such as meditation, Biofeedback, breath work, restorative yoga, prayer, etc. If so, describe what you do and how often.

Tell me what you eat and drink - in general.

And what you eat and when. Breakfast, Snack, Lunch, Snack, Dinner, After dinner.

Do you have cravings?

Do you have energy drops?

Do you have any digestion issues?

Is there anything else you’d like me to know?

Disclosure and waiver- for your safety and mine. This consultation is not meant to be a substitute for any physical or mental healthcare you require. Consult with your primary care physician before undergoing any health or lifestyle changes. Katharine Stewart is here to educate, guide and support you on your health journey as you take responsibility for your body and your health. She is not a primary health physician nor is she dispensing medical advice. By accepting here you acknowledge your personal responsibility and release Katharine Stewart from any and all liability.

Thank you so much for taking the time to fill this out as thoroughly as you can!

I look forward to helping you feel better!

KateStewart

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