Intake Paperwork - Moss Herbalism

Name

First

Last

Email

Age

Pronouns

Primary Health Goals for this consult

Please list any health conditions you are currently experiencing

List any condition regardless of relation to the health goal we are working on

Please list major past medical history

Please list any allergies

Are you currently taking any medications

Yes
No

If Yes list medcations here

List any herbs or supplements you are currently taking

Name, Dosage, Frequency, Length of Time, Reasons for Taking

Have you had a surgery in the last 4 months?

Yes
No

Are you currently pregnant or breastfeeding?

Yes Pregnant
Yes Breastfeeding
No

Please list history of pregnancies and years if applicable:

What health practioners are you currently working with:

Do you experience:

Indicate how happy you are with your nutrition

Selected Value: 0

1=I feel under nourished by my food 10= I am getting everything I need from my nutritional intake

Do you have nutrition/diet preferences you adhere to?

Indicate the level of stress in your life

Selected Value: 0

1= low 10= Unbearable

Indicate the qualty of sleep you get

Selected Value: 0

1=Insomnia 10= 8+ hours of restful sleep

Indicate how consistantly you have movement in your life

Selected Value: 0

1 = Sedentary 10 = Movement is an established habit

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 education around herbalism and holistic health habits. 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 reccomendation and will include synergystic 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.

Herbalism Consult – New Client Intake Paperwork