Herb Consultation Intake Form

Name______________________________________________________ Date_____________________________

e-mail____________________________________ Phone ___________________________________

Age__________________ Height_______________________ Weight______________________________

Occupation_______________________________________________

Chief Complaint (reason for seeking custom formula) . Please be specific about symptoms you are currently experiencing.

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When did this begin?

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Previous Surgeries, Hospitalizations, relevant health conditions

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Current Medications

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Allergies, Pain, Long term Ailments

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