Blue Crow Botanicals
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INTAKE/HISTORY FORM

Date_______             Date of Birth_______________

Name_______________________________________________

Address_____________________________________________

____________________________________________________

Phone _____________________   Cell_____________________

Email________________________________________________

Reason/s for consult

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Do you have previous experience with herbs_______natural supplements________ acupuncture/bodywork___________

Diet
Typical Breakfast

Typical Lunch

Typical Dinner

Desserts and/or snacks

Favorite foods or cravings

Beverages

Body weight in pounds______Water consumed in ounces per day.

Sleep Pattern
_____fall asleep easily______can’t fall asleep

Wake______times per night_______what time

How do you feel in the AM?_____________________________

Do you feel rested and energetic for your day?________________________

Bowels
Moves
_____daily_____every 2-3 days_______less often     difficult_______  easy________

loose__________hard_________ complete______incomplete_______

do you take probiotics________  How much?__________

Mood/Emotions

Currently____________________________________________________________________________________________

Past issues__________________________________________________________________________________________

Libido _____absent _____low_______average______good

Work 
_____satisfying______unsatisfying_______retired ________unemployed

_______work too hard   ________work a reasonable amount of hrs  _____avg. per week

Hobbies or favorite acitivities
_____________________________________________________________________________________________________

Exercise

_______intense________average________infrequent________not at all

_______frequency________type of activity__________level of enjoyment

Energy Level

____exhausted_______tired occasionally______up and down______good energy

Menses 
______ Menopausal_________ Number of Preg_____Number of births_______

Birth Control_________  Discomfort________________

Medications
____________________________________________________________________________________________________

Surgeries
____________________________________________________________________________________________________________


Significant Medical History with dates,

Significant Mental/Emotional History with Dates.

Childhood issues and illnesses.

Relationship to family of origin.

Current network of support

Any other information that would be useful to share.


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The information on this website is intended for educational purposes only. It is not intended to
diagnose, prescribe, treat or cure illness or to be used to replace  professional medical attention.
  • Home
  • Single Extracts
  • Formulas
  • Oils and Salves
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    • Intake Form
  • Blog
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  • Sale
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