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All Services
Clinical Consults
Intake Paperwork
Return Paperwork
Quick Recommendations
Workshops
Specialities
About
ADHD & Focus Support
Histamine & MCAS
Postpartum Packages
Women’s Hormone Health
Articles
Newsletter
Shop
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Herbalism Consult – New Client Intake Paperwork
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email
*
Age
Pronouns
She/Her
He/Him
They/Them
Other
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
Do you have any past diagnoses, chronic conditions, or significant medical history?”
Please add aproximate years
Please list any allergies
*
Are you currently taking any medications
*
Yes
No
If Yes list medications here
Please list any herbs or supplements you are currently taking, including dosage and frequency
*
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 is your current menstrual cycle like (length, flow, regularity, PMS symptoms) if applicable:
What health practioners are you currently working with:
Do you experience:
Anxiety
Depression
Grief
ADD/ADHD
Irritability
Panic Attacks
Dissociation
Mental Sluggishness
Fatigue/Burnout
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?
(e.g. vegetarian, gluten-free, low histamine)
Indicate the level of stress in your life
Selected Value:
0
1= low 10= Unbearable
Indicate the quality of sleep you get
Selected Value:
0
1=Insomnia 10= 8+ hours of restful sleep
Indicate how consistently 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 consults is a collaborative effort to improve your health with your personal expressions and my education around herbalism and holistic health habits. 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 except for helping to assess the safety of the use of herbs in conjunction with the pharmaceuticals you may already be using. I have no objections and encourage clients being seen or evaluated by their own medical doctor. If you have any questions or concerns about anything we discuss in a consult, I highly recommend you discuss them with your physician to be sure you are getting the best possible care. I encourage you to share and discuss my recommendations with any other health care professionals. 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. If you do purchase from me please note that herbs are either purchased from retailers or forgaed/purchased from local farmers. All remedies are researched and prepared with educated medicine-making techniques and the best possible extraction methods. Dosing with remedies can be variable as phytoconstituent levels vary from plant to plant. I do my best work to ensure that all remedies are dosed appropriately for safe and effective results. The recommended herbs I suggest are not a replacement for the medications prescribed by your Medical Doctor. Any reaction or adverse symptom from taking a custom herbal formula is not the liability of Moss Herbalism or Cassidy Moss.
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