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Herbal Medicine Intake Form

I. Personal Information

Full Name

Date of Birth

Age

Gender

Contact Information

Phone Number

Email

Address






Emergency Contact

Full Name

Phone Number

Relationship

II. Health History

Primary Health Concerns (Please describe your main reasons for seeking herbal medicine):

 

Medical History:

 

Have you been diagnosed with any medical conditions?

If yes, please list:

Are you currently under the care of a healthcare provider?

If yes, please provide details:

 

Surgical History:

 

Have you had any surgeries?

If yes, please list:

 

Medications and Supplements:

 

Are you currently taking any prescription medications?

If yes, please list:

Are you currently taking any over-the-counter medications or supplements?

If yes, please list:

 

Allergies:

 

Do you have any known allergies (e.g., food, medications, herbs, environmental)?

If yes, please list:

III. Lifestyle and Habits

Diet:

 

Describe your typical diet (e.g., vegetarian, omnivore, etc.):

Do you have any dietary restrictions or preferences?

If yes, please list:

 

Exercise:

 

How often do you exercise?

Daily

3-4 times/week

Rarely

Never

Type of exercise:

 

Sleep:

 

How many hours of sleep do you get per night?

<5

5-7

7-9

>9

Do you have trouble sleeping?

If yes, please describe:

 

Stress Levels:

 

How would you rate your stress levels?

Low

Moderate

High

Very High

Do you use any stress management techniques?

If yes, please list:

 

Substance Use:

 

Do you smoke or use tobacco products?

Do you consume alcohol?

If yes, how often?

Daily

Weekly

Occasionally

Rarely

Do you use recreational drugs?

IV. Herbal Medicine Suitability

Previous Experience with Herbal Medicine:

 

Have you used herbal remedies or supplements before?

If yes, please describe:

 

Goals for Herbal Medicine:

 

What are your primary goals for using herbal medicine? (e.g., stress relief, immune support, digestive health, etc.):

 

Concerns or Preferences:

 

Do you have any concerns about using herbal medicine?

If yes, please describe:

Do you have any preferences (e.g., taste, form of herbal medicine)?

If yes, please describe:

 

Pregnancy/Breastfeeding:

 

Are you pregnant or breastfeeding?

Yes

No

Not applicable

 

Other Therapies:

 

Are you currently using any other complementary therapies (e.g., acupuncture, chiropractic, etc.)?

If yes, please list:

V. Consent and Agreement

Consent for Treatment:

 

I understand that herbal medicine is a complementary therapy and not a substitute for medical diagnosis or treatment.

I agree to inform my healthcare provider(s) about my use of herbal medicine.

 

Confidentiality:

 

I understand that my personal and health information will be kept confidential.

 

Signature:

 

Client Signature:

Client Intake Form Insights

Please remove this client intake form insights section before publishing.


This will help you understand why each piece of information is collected and how it contributes to a safe, effective, and personalized herbal medicine consultation.

Section 1: Personal Information

This section collects basic demographic and contact details to establish the client's identity and ensure proper communication.

  1. Full Name: Identifies the client for record-keeping and personalized care.
  2. Date of Birth/Age: Helps assess age-related health concerns and tailor herbal recommendations accordingly.
  3. Gender: Some health conditions and herbal remedies may have gender-specific considerations.
  4. Contact Information: Ensures the practitioner can reach the client for follow-ups or emergencies.
  5. Emergency Contact: Provides a safety net in case of adverse reactions or emergencies during treatment.

Section 2: Health History

This section gathers critical information about the client's medical background, which is essential for identifying contraindications and ensuring the safety of herbal treatments.

  1. Primary Health Concerns:
    Helps the practitioner focus on the client's main issues and tailor the consultation accordingly.
    Example: A client seeking help for digestive issues may require different herbs than someone seeking stress relief.
  2. Medical History:
    Identifies chronic conditions (e.g., diabetes, hypertension) that may influence herb selection.
    Example: Certain herbs may interact with conditions like high blood pressure or thyroid disorders.
  3. Surgical History:
    Highlights past surgeries that may affect current health or require special considerations.
    Example: A client with a history of gallbladder removal may need digestive support.
  4. Medications and Supplements:
    Identifies potential herb-drug interactions.
    Example: St. John’s Wort can interact with antidepressants, and garlic may affect blood-thinning medications.
  5. Allergies:
    Prevents adverse reactions to herbs or related substances.
    Example: A client allergic to ragweed may also react to chamomile or echinacea.

Section 3: Lifestyle and Habits

This section provides insight into the client's daily habits, which can influence their health and response to herbal medicine.

  1. Diet:
    Helps assess nutritional status and identify dietary factors that may contribute to health issues.
    Example: A client with a high-sugar diet may benefit from herbs that support blood sugar regulation.
  2. Exercise:
    Indicates physical activity levels, which can affect energy, circulation, and overall health.
    Example: A sedentary client may benefit from herbs that boost circulation and energy.
  3. Sleep:
    Highlights sleep quality and patterns, which are crucial for overall well-being.
    Example: A client with insomnia may benefit from calming herbs like valerian or passionflower.
  4. Stress Levels:
    Assesses the impact of stress on health and identifies the need for adaptogenic or calming herbs.
    Example: A highly stressed client may benefit from ashwagandha or lemon balm.
  5. Substance Use:
    Identifies habits that may affect health or interact with herbal remedies.
    Example: Smoking may reduce the effectiveness of certain herbs, and alcohol may exacerbate liver stress.

Section 4: Herbal Medicine Suitability

This section evaluates the client's experience with herbal medicine, their goals, and any preferences or concerns.

  1. Previous Experience with Herbal Medicine:
    Helps the practitioner understand the client’s familiarity with herbs and avoid repeating ineffective treatments.
    Example: A client who has tried and disliked the taste of herbal teas may prefer capsules or tinctures.
  2. Goals for Herbal Medicine:
    Clarifies the client’s expectations and ensures the practitioner addresses their primary concerns.
    Example: A client seeking immune support may benefit from echinacea or astragalus.
  3. Concerns or Preferences:
    Ensures the client’s comfort and adherence to the treatment plan.
    Example: A client who dislikes strong flavors may prefer milder herbs or alternative forms like capsules.
  4. Pregnancy/Breastfeeding:
    Identifies special considerations for pregnant or breastfeeding clients, as some herbs are contraindicated.
    Example: Herbs like black cohosh or goldenseal are not recommended during pregnancy.
  5. Other Therapies:
    Ensures the practitioner is aware of other treatments the client is using to avoid overlaps or conflicts.
    Example: A client receiving acupuncture may benefit from herbs that enhance the effects of acupuncture.

Section 5: Consent and Agreement

This section ensures the client understands the nature of herbal medicine and agrees to the terms of the consultation.

  1. Consent for Treatment:
    Confirms the client’s understanding that herbal medicine is complementary and not a substitute for medical care.
    Encourages open communication with their healthcare provider.
  2. Confidentiality:
    Reassures the client that their personal and health information will be kept private.
  3. Signature:
    Formalizes the client’s agreement to proceed with the consultation and treatment.

Additional Notes or Questions for the Practitioner

This space allows the client to share any additional information or ask questions that may not have been covered in the form. It also gives the practitioner an opportunity to address specific concerns or clarify details.

Why This Form is Important

  1. Personalization: The form ensures that herbal recommendations are tailored to the client’s unique health profile, goals, and preferences.
  2. Safety: By identifying medical conditions, medications, and allergies, the practitioner can avoid harmful herb-drug interactions or contraindications.
  3. Effectiveness: Understanding the client’s lifestyle and habits helps the practitioner recommend herbs that align with their daily routine and address root causes of health issues.
  4. Legal and Ethical Compliance: The consent and confidentiality sections protect both the client and the practitioner, ensuring transparency and trust.

This form is a foundational tool for a successful herbal medicine consultation, enabling the practitioner to provide safe, effective, and personalized care.


Mandatory Questions Recommendation

Please remove this mandatory questions recommendation section before publishing.


The mandatory questions are those that ensure safety, legal compliance, and effective treatment planning. Below are the essential questions that must be included in any herbal medicine intake form, along with explanations for their necessity.

Mandatory Questions (Cannot Be Skipped)

1. Personal Information

Full Name – Legal identification and record-keeping.
Date of Birth / Age – Some herbs are contraindicated for children, elderly, or pregnant individuals.
Emergency Contact – Required in case of adverse reactions.

2. Health History (Critical for Safety)

Current Medications & Supplements – To avoid herb-drug interactions (e.g., blood thinners + garlic/ginkgo).
Known Allergies – Prevents allergic reactions (e.g., ragweed allergy = avoid chamomile/echinacea).
Major Medical Conditions – Some herbs are unsafe for certain conditions (e.g., high blood pressure + licorice root).

3. Pregnancy & Breastfeeding Status

"Are you pregnant, breastfeeding, or trying to conceive?"

  • Many herbs are contraindicated in pregnancy (e.g., black cohosh, pennyroyal).
  • Some herbs affect milk supply (e.g., sage may reduce lactation).

4. Primary Health Concerns

"What are your main health goals for herbal medicine?"

  • Ensures the consultation is focused and relevant (e.g., stress vs. digestive issues require different herbs).

5. Consent & Liability Agreement

"Do you understand that herbal medicine is complementary and not a substitute for medical care?"
"Do you consent to herbal treatment and agree to inform your doctor?"

  • Legal protection for the practitioner.
  • Ensures the client knows herbal medicine is not a replacement for conventional care.

Conditionally Mandatory Questions

These should be asked if applicable based on initial responses:

  • "Are you scheduled for surgery soon?" (Some herbs affect bleeding, e.g., ginkgo, garlic).
  • "Do you have a history of liver/kidney disease?" (Some herbs are hepatotoxic, e.g., kava, comfrey).
  • "Have you had adverse reactions to herbs before?" (Helps avoid re-exposure).

Why These Are Mandatory

  1. Avoids Harm – Prevents dangerous herb-drug or herb-disease interactions.
  2. Legal Protection – Ensures informed consent and reduces liability risks.
  3. Effective Treatment – Helps tailor herbs to the client’s specific needs and health status.

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