New Client Form Contact Information First Name* Last Name* Birth Date* How did you hear about our clinic?* Social Media/Website Friend/Family Member In-Person Clinic Visit Other Cell Phone Number* May we text or email you from time to time about events, classes and clinics we are hosting? YES! I want to stay informed about your events, classes and clinics. No thanks, I do not wish to receive emails or texts from Wild Roots about upcoming clinics, classes or events. Do you need an interpreter for your visit?* Yes No Email Address Information Street Address* City* State* AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code* Personal Information Height* Weight * Pregnant or nursing? * Pregnant Nursing Neither Maybe If nursing, age of the child in months Summary of Health If a question is not relevant to you, please enter "Not applicable" for required fields. Overall, how optimistic are you about your personal health? * Not very optimistic Somewhat optimistic Very optimistic How many times a week do you have difficulty sleeping? * How would you rate your energy level over the past week?* Very Poor Poor Average Good Very Good My appetite over the past week has been:* Less than usual Average/about the same as always Better than usual Other How many times in the past week have you needed supplements for pain, allergies, insomnia, digestion, etc?* What is your average daily pain level over the past week?* 1 - Very little or no pain 2 3 4 5 - Serious pain that affects my enjoyment of life How many days of work, school, or caregiving have you missed due to health issues in the past month? * How many visits to a medical doctor, therapist, or other medical specialist have you had in the past month? * Medical History * Past surgeries or diagnostic studies* List any allergies to any medications or plant families * Current supplements or vitamins * Current Medications + what for?* Can you take tinctures based in alcohol?* Yes No I would prefer other options Please select your primary concern* Allergy/Sinus Autoimmune Chronic Disease Circulation Diabetes Digestion Heart Health Hormone Insomnia Menopause Menstruation Mental Health Pain (Headache, joint, etc) Skin Conditions Weight Other (please explain next) Please provide additional information on your primary concern* How long has issue been going on?* What treatment has been recommended?* What have you tried that has worked?* What have you tried that has NOT worked?* Anything else your herbalist should know? Privacy and Informed Consent Please read Wild Roots People's Clinic staff are herbalists. The recommendations they provide are based on an understanding of herbs. The recommendations are not provided for the purpose of a medical diagnosis or medical treatment. The recommendations are based on the herbalist's understanding of the use of herbs to support health and wellness. Wild Roots People's Clinic does not diagnose, treat, or cure any diseases. Recommendations may include number of different approaches to address the symptoms as they are presented and evolve over the course of your visits with Wild Roots People's Clinic. These may include herbalism, diet and lifestyle suggestions, vitamins and supplements, and massage. Your health is your responsibility. Herbalism must be used responsibly. People respond differently to different forms of herbal preparations. Also, some herbs should not be taken with certain pharmaceutical drugs. It is therefore recommended that your healthcare provider(s) be informed of any herbs you are taking. It is very important that you inform your Wild Roots People's Clinic herbalist immediately of any conditions you are suffering from, as well as any medications (prescription or over the counter) that you take, or if you could be pregnant or are breast-feeding. Records will be kept of the herbalism services provided to you by Wild Roots People's Clinic. The clinic is not subject to HIPAA under law, however, it will do its best to maintain the confidentiality of your records, and will not release your records to other entities without your consent, unless required by law. There are no guarantees that the treatment provided will relieve you of the symptoms or conditions presented to the herbalist(s). There may be a difference of opinion on how best to treat your symptoms or condition. I have read and understood the above-stated policies and information. I understand that an herbal approach may require time, additional practices, and compliance with recommendations made by my healthcare providers. My initials below indicate my understanding of the information provided in this document. I willingly consent to an herbal assessment by one of the Wild Roots People's Clinic herbalists. Please TYPE YOUR INITIALS BELOW, to acknowledge that you have read and understand the above information *
