Consultation Form This form is for and herbal consultation. It is not a substitute for regular medical care. It can offer guidance and information so that you may better understand and make educated decisions about your health. If under 18 a guardian must be present. Please fill out what you feel comfortable with shearing. While more information will help find the right plants for you, do not feel like you have to share something you are not comfortable with. All client records are confidential. Forbidden Foliage holds in strict confidence all information gathered and discussed with you, unless you specifically request otherwise. Basic Information If under 18 age height and weight are required. If you are filling this form out for someone else the preparer section is required. Full Name (Required) Email Address (Required) Phone Number (Required) Age (Optional) Weight (Optional) Height (Optional) Prefer contact method (Required) Text Phone Call Email Primary Goals (Required) Secondary Goals (Optional) Preparer Preparer's Full Name (Optional) Relation to client (Optional) Next Health While not required this section is important to help find herbs that will not have contraindications for you. Any current health issues? (Optional) List the medications you are taking, dosage, frequency, how long you have been tacking it, and the reason for taking it (Optional) List the herbs you are taking, dosage, frequency, how long you have been tacking it, and the reason for taking it (Optional) List the vitamins you are taking, dosage, frequency, how long you have been tacking it, and the reason for taking it (Optional) Do you have cardio vascular issues? (Optional) Do you have organ issues (liver, kidney)? (Optional) What allergies do you have if any? What is your allergic reaction like? (Optional) Any family health issues you are concerned about effecting you? (circulatory, cancer, organ failure) (Optional) Any important health issues in the past? (Optional) Any other reasons that herb or medication may be contraindicated for you? (Optional) Back Next Preferences Medicine is easier to take and more effective if you enjoy taking it. Fill out this section with any and all preferences to better get suggestions that fit your life. What is you preferred herbal intake method? (Optional) Tincture alcohol Tincture Glycerin Tea Powder Food Is there any way that you do not like or prefer to take herbs? (Optional) What flavors do you like? (Optional) What flavors do you do not like? (Optional) Are there any herbs that you love or hate? (Optional) Other preference information you would like to add (Optional) Back Next Work and Stress Work What do you do for a living? (Optional) How many hours do you work a week? (Optional) Do you enjoy your work? (Optional) Select... Yes, I enjoy my work most of the time No, I do not enjoy my work most of the time How stressful is your work? (Optional) Select... 1 not stressfull at all 2 3 4 5 Moderately stressful, but does not come home with me 6 7 8 9 10 Unbearably stressful Stress This can be work or home related What does your great day look like? (Optional) What does your average day look like? (Optional) What does your stress level on an average day look like? (Optional) Select... 1 not stressfull at all 2 3 4 5 Moderately stressful, but does not come home with me 6 7 8 9 10 Unbearably stressful What does your stressful day look like? (Optional) What does your stress level on an stressful day look like? (Optional) Select... 1 not stressfull at all 2 3 4 5 Moderately stressful, but does not come home with me 6 7 8 9 10 Unbearably stressful What do you do to rest/relax? (Optional) What do you do for fun? (Optional) Anything else you would like to say about your work life or stress (Optional) Back Next Daily Life Do you have a significant other? (Optional) I have a significant other I do not have a significant other I am happy with my significant other situation I am not happy with my significant other situation Do you have support people? (Optional) Significant other supports me in time of need Family supports me in time of need Friends supports me in time of need I do not have someone that supports me in time of need Are you pregnant or want to get pregnant? (Optional) Select... I am not pregnant and do not want to be I am not pregnant and do want to be I am pregnant and do want to be I am pregnant and do not want to be Do you have kids? (Optional) No Kids I have Kid(s) that live with me I have some Kid(s) that live with me I have Kid(s) that do not live with me I have 1-2 kids I have 3-4 kids I have <4 kids Want more kids On average how many times to you get sick in a year? (Optional) How long do you stay sick when you get sick? (Optional) When you get cuts or bruising on average how fast do they heal? (Optional) How many hours on average do you sleep a day/night? (Optional) Select... 1-4 hours 5-6 hours 7-8 hours 9-11 hours >=12 hours What is the quality of your sleep? (Optional) Do you get woken up or wake up in the night? (Optional) Are you happy with your sleep? (Optional) I would like more sleep I feel like I sleep to much I would like better quality sleep I am happy with my sleep What time do you go to bed and what time do you wake up? (Optional) What are you dreams like? (do you have them, are they good or bad) (Optional) Other life or sleep information you would like to add (Optional) Back Next Diet What do your meals look like a good day? (ex. Protein for breakfast, salad for lunch, eat out for dinner with a mix of protein, fat, and greens) (Optional) What do your meals look like a bad day? (ex. Protein for breakfast, salad for lunch, eat out for dinner with a mix of protein, fat, and greens) (Optional) Do you have variety in your diet? (Optional) Check the items that you consume most days (Optional) Vegetables (carrots, spinach, potato...) Fruit (orange, apple grapes...) Saturated fat (lard, butter, solid fat...) Non saturated fat (vegetable oil, olive oil...) Meat (chicken, pork, beef...) Fish (salmon, tilapia...) Legumes(peanuts, beans, peas...) Nuts and seeds (pumpkin seeds, walnuts...) Whole grains (Rice, Oats, wheat...) Baked goods (bread, doughnuts, cookies...) Fermented foods (Kimchi, Miso...) Sugary (candy bars, gummies...) Dairy (milk, cheese, yogurt...) Juice (Koolaide, fruit juice...) Tea (Green tea, medicinal tea..) Water Sodas (pepsi, cocola, sprite...) Alcohol (mixed drins, beer...) Caffeine (Cofee, Energy drinks...) Check the items that you consume most Weeks (Optional) Vegetables (carrots, spinach, potato...) Fruit (orange, apple grapes...) Saturated fat (lard, butter, solid fat...) Non saturated fat (vegetable oil, olive oil...) Meat (chicken, pork, beef...) Fish (salmon, tilapia...) Legumes(peanuts, beans, peas...) Nuts and seeds (pumpkin seeds, walnuts...) Whole grains (Rice, Oats, wheat...) Baked goods (bread, doughnuts, cookies...) Fermented foods (Kimchi, Miso...) Sugary (candy bars, gummies...) Dairy (milk, cheese, yogurt...) Juice (Koolaide, fruit juice...) Tea (Green tea, medicinal tea..) Water Sodas (pepsi, cocola, sprite...) Alcohol (mixed drins, beer...) Caffeine (Cofee, Energy drinks...) Other diet information you would like to add (Optional) Anything you would like to add (Optional) Beginning Please make sure the required information in the first section is filled out. Submit will not function if all required information is not filled out. Submit