Book A Consult

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Book A Consult

Email wildeastherbals@gmail.com
or call 902-471-8923
to book a 90-minute consult.
Please fill out this intake form
before your appointment

Wild East Herbal Wellness Client Intake

Date*

First name*

Last name*

Birthday*

Year

Month

Day

Gender

Address

Country/Region

Address

City

Zip / Postal code

Email*

Phone

Occupation

Number and ages of children

Marital status

Medical Information

This is a confidential record of your medical history and will not be released to any person unless you have authorized us to do so. Please complete this section as thoroughly as possible. Thank you.

What are the main health concerns you would like to address?*

History of current health concerns

Are you currently seeing a health care or alternative care professional? If yes, for what reasons?

Past Medical History

Vaccinations

Antibiotic use

Relevant illnesses

Surgeries

Allergies/sensitivities

Medications/Supplements/Herbs

Please list any medications, vitamins, supplements or herbs you are presently taking, the reason you are taking them and for how long.

Medications/Supplements/Herbs

Family History (relevant illnesses or conditions)

Father

Mother

Siblings

Children

Other relatives

Personal Health Details

Height/weight

Blood pressure

Are you pregnant?

Do you drink alcohol

Do you use recreational drugs?

Caffeine consumption

Tobacco Use

Physical activities

Mental wellness

Alternative therapies

Do you have a spiritual practice?

Are you able to take remedies made with alcohol (tinctures)?

Review of Symptoms

Please indicate if you have experienced any of the following in the past three months.

EYES

poor vision

cataracts

blurred vision

glaucoma

eye pain

spots in front of eyes

Other

EARS

earaches

ringing in ears

ear infections

loss of hearing

Other

THROAT/SINUSES

sore throat

mucous in throat

swollen glands

sinus congestion

nose bleeds

frequent colds

Other

FACE/HEAD

cold sores

facial pain

grinding teeth

clicking jaw

dizziness

canker sores

Other

MUSCULOSKELETAL

neck pain

back pain

muscle pain

muscle weakness

stiffness

reduced range of movement

Other

Do you see a massage therapist, chiropractor, or osteopath?

NEURO/PSYCHOLOGICAL

poor sleep

poor memory

foggy or spacey feeling

difficulty concentrating

headaches

migraines

depression

irritability

anxiety

seizures

numbness

lack of coordination

lack of balance

high stress levels

Other

Hours of sleep per 24 hours

Do you remember your dreams?

yes

no

GASTRO-INTESTINAL

nausea

heartburn

bloating

gas

abdominal pain

indigestion

difficulty swallowing

vomiting

constipation

diarrhoea

rectal pain

haemorrhoids

black stools

blood in stool

pale stools

mucous in stool

poor appetite

food cravings

bad breath

Other

BOWEL MOVEMENTS

loose

normal

hard

# bowel movements per day

URINARY

pain on urination

urgency to urinate

difficulty stopping or starting flow

frequent urination

inability to hold urination

kidney stones

urinary tract infections

blood in urine

irregular flow

decrease in flow

Other

FEMALE REPRODUCTIVE

heavy bleeding

clots

bleeding between periods

discharge

severe menstrual cramps

breast lumps

pain with intercourse

PMS

Age at first period

Duration of bleeding

Length of cycles

Age at menopause

Date and result of last Pap test

#pregnancies/births/miscarriages/premature births/abortions

Types of birth control used

Do you practice breast self examination?

yes

no

MALE REPRODUCTIVE

prostate enlargement

jock itch

erectile dysfunction

Other

GENERAL

fatigue

night sweats

sudden energy drops

slow metabolism

weight loss

weight gain

fevers

excessive thirst

intolerance to heat

intolerance to cold

chills

Other

CARDIOVASCULAR

high blood pressure

low blood pressure

chest pain

irregular heart beat

fainting

cold hands or feet

Other

RESPIRATORY

cough

bronchitis

asthma

coughing blood

pneumonia

shortness of breath

pain with breathing

production of phlegm

Other

SKIN/HAIR

rashes

itching

pimples

eczema

recent moles

poorly healing sores

hives

psoriasis

change in skin texture

hair loss

dandruff

Other

Phew. You've reached the end. Thank you for taking the time to fill this out.

Home
Book A Consult

bottom of page

Book a consult

Email wildeastherbals@gmail.com or call 902-471-8923 to book a 90-minute consult. Please fill out this intake form before your appointment

Wild East Herbal Wellness Client Intake

Medical Information

Past Medical History

Medications/Supplements/Herbs

Family History (relevant illnesses or conditions)

Personal Health Details

Review of Symptoms

Email wildeastherbals@gmail.com
or call 902-471-8923
to book a 90-minute consult.
Please fill out this intake form
before your appointment