Wild Herbals, LLC

Dabney Vaccaro, BS, RDH,

Clinical Herbalist & Health Coach

540.908.5404

Personal Health Profile

Name: _______________ Date: _

Address: ________________________________________________________________________

Phone #’s Home: _ Work: ______________

E-mail: ___________________________________

Date of Birth: __________ Age: _ Weight: _ Height: ___

Blood Type: _______

Occupation: ___________________________________________________________________________

Relationship Status: Partner’s Name_____

Partner’s Occupation: _____________________________________________

Names & ages of Children: _ __________________________

Present Health Concerns

Physician’s Diagnosis: ________________________________________________________________

Physician’s Treatment: _______________________________________________________________

Another practitioner’s response: _____________________________________________________

Do you have any allergies? To what? __________________________________________________

Please list any food allergies ________________________________________________________

Please list any allergies to any medications: __________________________________________

Please list any medications taken regularly, either prescribed, recreational or over-the-counter: ______________________________________________________________________________________

______________________________________________________________________________________

Please list any vitamins, minerals, or herbal supplements taken regularly:

______________________________________________________________________________________

Do you run hot or cold?

Would you describe yourself dry or damp?

Body System Health Profile

Please leave blank if not applicable

1 = sometimes 2 = often 3 = major concern

Circulatory

_____ High Blood Pressure

_____ Low Blood Pressure

_ Palpitations
_ High cholesterol

_____ Triglycerides

___ Varicose veins
_ Spider veins
_ Cold hands & feet
_ Poor circulation
_ Pain in chest
_ Previous heart stroke
_ Swelling in ankles/joints
_ Other: _______________________________

Respiratory

___ Allergies
_ Asthma
_ Sinusitis
___ Post nasal drip

_ Sore throat
_ Lung congestion

_____ Difficulty breathing

_____ Cough

___ History of Tuberculosis
_ Recurrent influenza
_ Cold
_ Other: ______________________________

Eyes, Ears, Nose, Throat & Digestive

_____ Eye pain, wet/dry

___ Failing vision
_ Ear aches
___ Hearing loss

___ Mouth ulcers
_ Halitosis - bad breath
_ Hiatal hernia
_ Bloating
_ History of Hepatitis
_ Gall Stones
___ Hypoglycemia (Low Blood Sugar)

___ Indigestion
_ Ulcers
_ Constipation
_ Diarrhea
_ Irritable Bowel Syndrome
_ Polyps
_ Hemorrhoids
_ Bleeding from Anus
_ Flatulence
___ Have you traveled abroad often?

___ Ringing in the ears/Tinnitus
_ Hay fever
_ Tonsils
_ Other: _______________________________

Skin

___ Boils
_ Acne
_ Eczema
_ Psoriasis
_ Bruise Easily
_ Herpes simplex
_ Slow wound healing
_ Other: _______________________________

List where: __________________________

Urinary

___ Bladder infections (cystitis)
_ Kidney stones
___ Water retention /swelling of ankles/legs

___ Incontinence
_ Painful urination
_ Excessive urination
_ Lower back pain
___ Dark circles under the eyes

Musculo/skeletal

___ Stiffness
_ Bursitis
_ Torn ligaments
_ Backache, upper/lower
_ Broken bones: List: ____________________

___ Arthritis
_ Mobility restriction
___ Gout

Ovarian, Uterine, Vaginal Health

_ Pregnancies, Date: ____________

Miscarriage Date: _____________

Abortion Date: __________

_____ Contraceptive use:

List type(s) & how long: _______________________________________________

_ Sexually transmitted disease, List Type if known: __________________________
_ Hysterectomy, Date: Reason: ________________________

_____ Uterine fibroids

_____ Ovarian cysts

_____ Endometriosis

_____ Vaginal Infection

_____ Breast pain

___ Genital Herpes
_ Cervical dysplasia
_ Painful intercourse
_ Anemia
___ Vaginal itching/discharge

_____ Infertility

_ Breast lump
_ Pelvic Inflammatory Disease

Menstruating

___ Irregular menstrual cycles
_ Heavy menstrual bleeding
_ Painful menstrual cramps
_ Bleeding between cycles
_ Absence of menstrual cycles
___ Dramatic mood swings around menstrual cycle

_ Other: _____________________________

Menopausal

_____ Lack of sex drive

___ Hot flashes
_ Dramatic mood swings
_ Dry vaginal lining
_ Osteoporosis
_ Vaginal bleeding
_ Estrogen Replacement Therapy
_ Other: ______________________________

Prostate, Penis, Testes

_ Impotence
_ Sexually transmitted disease

List Type if known: ______________________

_____ ProstatitiS

___ Lack of sex drive
_ Low sperm count
_ Low sperm motility
_ Other:______________________________

_ Difficulty with urination
_ Benign Prostatic Enlargement

_____ Premature Ejaculation

Endocrine Glands

___ Pituitary
_ Pineal
_ Thyroid
_ Hypothyroid
_ Hyperthyroid
_ Pancreas
_ Diabetes (Please indicate Type I_ or Type II___)

_____ Hypoglycemia

Lymphatic

___ Congestion
_ Swollen glands
_ Infection
_ Drainage
_ Other: ______________________________

Nervous System

___ Anxiety
_ Irritability
_ Stress
_ Headaches
_ Migraines
_ Insomnia
_ Depression
_ Attention Deficit/Hyperactivity
_ Mental sluggishness
_ Irritation to strong light
_ Shingles
_ Other: _______________________________

Immune System

_____ Auto-immune diseasE

_____ Chronic Fatigue Syndrome

_____Neuralgia

_____ Fibromyalgia

_____ Frequent Colds

_____ Vaccinations

_____ Chronic Fatigue Syndrome

_ Other: ____________________________

Past Medical History

Please list any surgeries you have had with date, including appendectomy, tonsillectomy, etc:

Please list any major injuries/accidents, including date:

Please list any traumatic experiences not treated medically (divorce, loss of lover, loss of job, death of loved one, etc) _ ________

Family Medical History

Maternal Medical History: _ ______________________

Paternal Medical History: ____________________

Sibling Medical History: _ ______Are you or any family members in a recovery program? If yes, which one? _ __________________________________________________________________________Common Physical Activities

Please list ________

Diet CONSUME: SOMETIMES OFTEN NEVER

Meat (Beef, Pork)

Dairy (Milk, cheese, yogurt)

Fried Foods

Sugar

Alcohol

Coffee/ Caffeine Soda/ Diet Soda Water

Tobacco/Canabis

Please list sample meals that you usually eat every day:

Breakfast___________________________________________________________________________

Lunch ______________________________________________________________________________

Dinner______________________________________________________________________________

Favorite snacks _____________________________________________________________________

CURRENT STATE OF EMOTIONS AND SPIRITUAL WELL-BEING

Please take time to think about and answer the following questions:

Are you satisfied with your living conditions? ______________________

If not , what would you changE?____________________________________________________________________________________________________________________________________________________________________________

Do you feel comfortable expressing your feelings?____________________________________

Which emotion do you find yourself in most of the time? _______________________________

Is there an excess of stress in your life? ______________________________________________

Are you satisfied with your job? ______________________________________________________

If in a relationship, are you satisfied with it? __________________________________________

Do you experience loneliness? _________________________________________________________

Do you sleep well? __________ How many hours (in a 24-hour period)? _

Do you dream? _____ Do you remember your dreams?

Are you satisfied with your energy level? __________________

Do you often feel exhausted? _________________

Is it easy to wake up in the morning? ________________________________

I understand that it is best to make an appointment and speak with the herbalist to make adjustments after the initial intake—usually four (4) weeks after the initial consultation.

If I want to add something to my current formula(s) or ask the herbalist to make a new formula for me without an appointment, I will incur a formulation fee of $25.00 per formula. This does not include a refill to an existing formulation.

Name & Date

____________________________________________

INFORMED CONSENT

Wild Herbals, LLC

ASSUMPTION OF RISK, RELEASE, COVENANT NOT TO SUE AND AGREEMENT TO HOLD HARMLESS

The undersigned hereby accepts and assumes all risk and liability associated with my taking the formula or tincture provided to me by my attending herbalist and Wild Herbals, LLC and its Clinic.

The undersigned hereby assumes any risk of an injury to myself or others in my care. The undersigned hereby releases, waives and discharges the attending herbalist and Wild Herbals, LLC, Plant from any and all liability from any loss or damage, and claims or damages resulting therefrom, on account of injury to persons or property, even injury resulting in death, whether caused by the attending herbalist and Wild Herbals, LLC, negligence or otherwise.

The undersigned will indemnify and hold harmless the attending herbalist and Wild Herbals, LLC, from any loss, liability, damage, expense or cost, whether caused by the attending herbalist and Wild Herbals, LLC, negligence or otherwise, and whether claimed by or through the undersigned or others, including costs and attorney’s fees incurred or suffered by reason of any claims, demands, actions, or suits which may be filed or claimed against the attending herbalist and Wild Herbals, LLC.

The undersigned covenants not to sue the attending herbalist and Wild Herbals, LLC and will not individually, or for others, or on behalf of minors, bring or prosecute, or in any way aid in the institution or prosecution of any claim or suit against the attending herbalist and/or Wild Herbals, LLC

References to the undersigned shall also include and obligate the undersigned’s spouse, family, children, guests, invitees, heirs, and assigns, and all persons claiming by or through the undersigned. References to Wild Herbals, LLC shall benefit Wild Herbals, LLC, and the Wild Herbals, LLC clinic its lessor, officers, employees, agents, successors and assigns.

Signed this _ day of ____________________, 20.

Signature: ______________________________________________________

Personal Health Profile

Name: _______________________________ Date: _________________

Address: ________________________________________________________________________

Phone #’s Home: _______________________ Work: ____________________________________

E-mail: ___________________________________

Date of Birth: ________________ Age: _________ Weight: _____ Height: _____

Blood Type: _______

Occupation: ___________________________________________________________________________

Relationship Status: __________ Partner’s Name_______________

Partner’s Occupation: _____________________________________________

Names & ages of Children: _____________________________________________________________ ______________________________________________________________________________________

Present Health Concerns

Physician’s Diagnosis: ________________________________________________________________

Physician’s Treatment: _______________________________________________________________

Another practitioner’s response: _____________________________________________________

Do you have any allergies? To what? __________________________________________________

Please list any food allergies ________________________________________________________

Please list any allergies to any medications: __________________________________________

Please list any medications taken regularly, either prescribed, recreational or over-the-counter: ______________________________________________________________________________________

______________________________________________________________________________________

Please list any vitamins, minerals, or herbal supplements taken regularly:

______________________________________________________________________________________

Do you run hot or cold?

Would you describe yourself dry or damp?

Body System Health Profile

Please leave blank if not applicable

1 = sometimes 2 = often 3 = major concern

Circulatory

_____ High Blood Pressure

_____ Low Blood Pressure

_____ Palpitations_____ High cholesterol

_____ Triglycerides

_____ Varicose veins_____ Spider veins_____ Cold hands & feet_____ Poor circulation_____ Pain in chest_____ Previous heart stroke_____ Swelling in ankles/joints_____ Other: _________________________________

Respiratory

_____ Allergies_____ Asthma_____ Sinusitis_____ Post nasal drip

_____ Sore throat_____ Lung congestion

_____ Difficulty breathing

_____ Cough

_____ History of Tuberculosis_____ Recurrent influenza_____ Cold_____ Other: ________________________________

Eyes, Ears, Nose, Throat & Digestive

_____ Eye pain, wet/dry

_____ Failing vision_____ Ear aches_____ Hearing loss

_____ Mouth ulcers_____ Halitosis - bad breath_____ Hiatal hernia_____ Bloating_____ History of Hepatitis_____ Gall Stones_____ Hypoglycemia (Low Blood Sugar)

_____ Indigestion_____ Ulcers_____ Constipation_____ Diarrhea_____ Irritable Bowel Syndrome_____ Polyps_____ Hemorrhoids_____ Bleeding from Anus_____ Flatulence_____ Have you traveled abroad often?

_____ Ringing in the ears/Tinnitus_____ Hay fever_____ Tonsils_____ Other: _________________________________

Skin

_____ Boils_____ Acne_____ Eczema_____ Psoriasis_____ Bruise Easily_____ Herpes simplex_____ Slow wound healing_____ Other: _________________________________

List where: __________________________

Urinary

_____ Bladder infections (cystitis)_____ Kidney stones_____ Water retention /swelling of ankles/legs

_____ Incontinence_____ Painful urination_____ Excessive urination_____ Lower back pain_____ Dark circles under the eyes

Musculo/skeletal

_____ Stiffness_____ Bursitis_____ Torn ligaments_____ Backache, upper/lower_____ Broken bones: List: ______________________

_____ Arthritis_____ Mobility restriction_____ Gout

Ovarian, Uterine, Vaginal Health

_____ Pregnancies, Date: ________________

Miscarriage Date: _____________

Abortion Date: __________

_____ Contraceptive use:

List type(s) & how long: _______________________________________________

_____ Sexually transmitted disease, List Type if known: _____________________________________ Hysterectomy, Date: ______________ Reason: ____________________________________

_____ Uterine fibroids

_____ Ovarian cysts

_____ Endometriosis

_____ Vaginal Infection

_____ Breast pain

_____ Genital Herpes_____ Cervical dysplasia_____ Painful intercourse_____ Anemia_____ Vaginal itching/discharge

_____ Infertility

_____ Breast lump_____ Pelvic Inflammatory Disease

Menstruating

_____ Irregular menstrual cycles_____ Heavy menstrual bleeding_____ Painful menstrual cramps_____ Bleeding between cycles_____ Absence of menstrual cycles_____ Dramatic mood swings around menstrual cycle

_____ Other: _________________________________

Menopausal

_____ Lack of sex drive

_____ Hot flashes_____ Dramatic mood swings_____ Dry vaginal lining_____ Osteoporosis_____ Vaginal bleeding_____ Estrogen Replacement Therapy_____ Other: ________________________________

Prostate, Penis, Testes

_____ Impotence_____ Sexually transmitted disease

List Type if known: ______________________

_____ ProstatitiS

_____ Lack of sex drive_____ Low sperm count_____ Low sperm motility_____ Other:________________________________

Name: _______________ Date: _

Phone #’s Home: _ Work: ______________

Date of Birth: __________ Age: _ Weight: _ Height: ___

Relationship Status: Partner’s Name_____

Names & ages of Children: _ __________________________

_ Palpitations
_ High cholesterol

___ Varicose veins
_ Spider veins
_ Cold hands & feet
_ Poor circulation
_ Pain in chest
_ Previous heart stroke
_ Swelling in ankles/joints
_ Other: _______________________________

___ Allergies
_ Asthma
_ Sinusitis
___ Post nasal drip

_ Sore throat
_ Lung congestion

___ History of Tuberculosis
_ Recurrent influenza
_ Cold
_ Other: ______________________________

___ Failing vision
_ Ear aches
___ Hearing loss

___ Mouth ulcers
_ Halitosis - bad breath
_ Hiatal hernia
_ Bloating
_ History of Hepatitis
_ Gall Stones
___ Hypoglycemia (Low Blood Sugar)

___ Indigestion
_ Ulcers
_ Constipation
_ Diarrhea
_ Irritable Bowel Syndrome
_ Polyps
_ Hemorrhoids
_ Bleeding from Anus
_ Flatulence
___ Have you traveled abroad often?

___ Ringing in the ears/Tinnitus
_ Hay fever
_ Tonsils
_ Other: _______________________________

___ Boils
_ Acne
_ Eczema
_ Psoriasis
_ Bruise Easily
_ Herpes simplex
_ Slow wound healing
_ Other: _______________________________

___ Bladder infections (cystitis)
_ Kidney stones
___ Water retention /swelling of ankles/legs

___ Incontinence
_ Painful urination
_ Excessive urination
_ Lower back pain
___ Dark circles under the eyes

___ Stiffness
_ Bursitis
_ Torn ligaments
_ Backache, upper/lower
_ Broken bones: List: ____________________

___ Arthritis
_ Mobility restriction
___ Gout

_ Pregnancies, Date: ____________

_ Sexually transmitted disease, List Type if known: __________________________
_ Hysterectomy, Date: Reason: ________________________

___ Genital Herpes
_ Cervical dysplasia
_ Painful intercourse
_ Anemia
___ Vaginal itching/discharge

_ Breast lump
_ Pelvic Inflammatory Disease

___ Irregular menstrual cycles
_ Heavy menstrual bleeding
_ Painful menstrual cramps
_ Bleeding between cycles
_ Absence of menstrual cycles
___ Dramatic mood swings around menstrual cycle

_ Other: _____________________________

___ Hot flashes
_ Dramatic mood swings
_ Dry vaginal lining
_ Osteoporosis
_ Vaginal bleeding
_ Estrogen Replacement Therapy
_ Other: ______________________________

_ Impotence
_ Sexually transmitted disease

___ Lack of sex drive
_ Low sperm count
_ Low sperm motility
_ Other:______________________________

_ Difficulty with urination
_ Benign Prostatic Enlargement

___ Pituitary
_ Pineal
_ Thyroid
_ Hypothyroid
_ Hyperthyroid
_ Pancreas
_ Diabetes (Please indicate Type I_ or Type II___)

___ Congestion
_ Swollen glands
_ Infection
_ Drainage
_ Other: ______________________________

___ Anxiety
_ Irritability
_ Stress
_ Headaches
_ Migraines
_ Insomnia
_ Depression
_ Attention Deficit/Hyperactivity
_ Mental sluggishness
_ Irritation to strong light
_ Shingles
_ Other: _______________________________

_ Other: ____________________________

Please list any surgeries you have had with date, including appendectomy, tonsillectomy, etc:

Please list any major injuries/accidents, including date:

Please list any traumatic experiences not treated medically (divorce, loss of lover, loss of job, death of loved one, etc) _ ________

Maternal Medical History: _ ______________________

Paternal Medical History: ____________________

Please list ________

Do you sleep well? __________ How many hours (in a 24-hour period)? _

Do you dream? _____ Do you remember your dreams?

Signed this _ day of ____________________, 20.