Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
(###)
###
####
Birthdate
*
MM
DD
YYYY
Gender
*
Female
Male
Trans
Non-binary
Other
Prefer not to say
Pronouns
*
Occupation
Primary Care Physician (PCP)
PCP Phone Number
(###)
###
####
How did you hear about Wild Rose Healing?
What is your primary concern for this visit?
*
General
Circulatory
Digestive
Bowel movements: How many per day?
Stool consistency:
Endocrine
Immune
Lymphatic
Musculoskeletal
Please rate your average daily pain level from 1 (lowest) to 10 (highest)
1
2
3
4
5
6
7
8
9
10
Back Pain:
Mental/Emotional
Stress Level:
Please rate your average daily stress level from 1 (lowest) to 10 (highest):
1
2
3
4
5
6
7
8
9
10
Nervous System
Reproductive - female bodied
Libido:
What is the color of your vaginal discharge?
Have you ever had an abnormal PAP? When?
If you are on birth control, what type?
Reproductive - male bodied
Libido:
If you use birth control, what type?
Respiratory
If you have phlegm, what color is it?
Skin
Urinary
History - please check any illnesses you have currently or in the past:
If you've had any STI's, which ones?
Please list any of the above that run in your family:
Please list any allergies or sensitivities to foods, drugs, chemical, or environmental substances:
Please list any Medications, Vitamins, Supplements, Herbs, and Homeopathics you are taking with dose and strength:
Please list any major injuries or accidents and year:
Please list any major surgeries and year:
If you exercise regularly, how often per week and for how long? What type of exercise?
How is your energy level overall?
When is your energy level the lowest?
When is your energy level the highest?
How many hours do you generally sleep?
Any sleep difficulties with:
If you drink alcohol, how much per day/week?
If you consume caffeine, what type and how much per day/week?
If you smoke or chew tobacco, how much per day/week?
If you consume sugar, how often per day/week?
If you consume salt, how often per day/week?
How many meals do you eat per day?
0
1
2
3
4 or more
How many snacks per day?
0
1
2
3
4 or more
What do you generally eat for breakfast?
What do you generally eat for lunch?
What do you generally eat for dinner?
What snacks do you generally reach for?
What foods do you crave?
How much water do you drink per day?
Are you on any special diets or avoiding any foods or food groups?
Are you receiving any other modalities (acupuncture, massage, naturopathic)?
What form of herbs are you most likely to take?
*
What form of herbs will you absolutely not take?
*
Anything else you'd like us to be aware of?
Employment Agreement: I hereby employ Lina Watanabe for purposes of consultation on her personal advice about dietary information. I understand the benefits and risks associated with herbal dietary supplements and give my full consent for herbal consultation and recommendations. No representations have been made to me concerning particular results to be expected through her methods. I understand that the results obtained will be partially dependent upon my own efforts. I understand that she does not prescribe treatments or medications, diagnose or treat physical or mental illness, or guarantee any particular results, and further understand that I should consult with my own doctor or health care practitioner for such treatment. I understand that I am responsible for all charges for services provided. I agree to provide 24 hour cancellation notice and if I fail to do so, I agree to pay the full appointment fee. Please sign your name electronically below:
*
Today's Date
*
MM
DD
YYYY
