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Postpartum Formulas Questionnaire

Name

First

Last

Age

Primary goals for recovery process

This will be generally formulated to support bleeding regulation, core recovery, and pelvic floor health - are there any other specific needs you would like me to meet with these formulas?

Please check all herbal products you have worked with previously

Loose Leaf Tea Blend
Tincture
Sitzbath

Tea blends are loose-leaf and will need to be brewed daily for medicinal results. Tinctures are alcohol-based but at a very small dose (similar to a cup of orange juice). Sitz baths are a topical preparation of tea that will need to be steeped, cooled, and put into a Sitz bath or regular bath to help soak the perineal area. Instructions will be provided along with the products. This is a great task for partners or caregivers to assist with

Please list any health conditions you have

List any health conditions you have, even if they do not seem related to your postpartum recovery.

Please list any major past medical history

Was/will this birth be a c-section?

Please list any allergies

Do you currently need or suspect you might need mood or anxiety support during your postpartum period?

Are you currently taking any medications

If Yes list medications here (if no write n/a)

List any herbs or supplements you are currently taking

On a scale of 1-5 how dry do you usually run?

Selected Value: 0

1 = VERY dry 5 = I typically don't have issues with feeling dry

Any questions or concerns you may have:

How did you hear about us?

Type your name to indicate understanding and acceptance of the below statement:

I, Cassidy Moss am a Clinical Herbalist, I am not a doctor and I am not licensed to diagnose, prescribe or medically treat any medical conditions. This questionnaire and custom formula is a collaborative effort to improve your health with your personal expressions and my intensive clinical training and experience in herbalism and holistic health. I am NOT a medical doctor nor do I practice standard Western medical assessment, diagnosis or treatment. I do not claim to cure disease, nor do I offer advice about the use of any type of pharmaceuticals or medications at any time. I have no objections to clients being seen or evaluated by their own medical doctor. If you have any questions or concerns about your health, I highly recommend you discuss them with your physician. I encourage you to share and discuss my recommendations with any other health care professionals. Understand that a full consult will provide a more comprehensive recommendation and will include synergistic supportive lifestyle recommendations. Clients are not obligated to buy any products from my practice and I encourage clients to purchase herbs wherever it is most convenient for them. The recommended herbs I suggest are not a replacement for the medications prescribed by your Medical Doctor. Any reaction or adverse symptom from taking the custom herbal formula is not the liability of Moss Herbalism or Cassidy Moss.