Floral Botanical Medicine
Floral
Botanical
Medicine

apothecary, microscopy practice & health consultations

154 REDLAND AVE · RUMFORD, RI 02916

FLORAL BOTANICAL MEDICINE

The Clinical Intake

HERBALIST CONSULTATION · NEW CLIENT

SECTION I

Client Information

Begin with the essentials.

Full Name

Date of Birth

Age

Address

City · State · Zip

Phone

Email

Emergency Contact — Name & Phone

SECTION II

Primary Concerns

What has brought you to the clinic.

What brings you in today?

Duration

Days Weeks Months Years

Diagnosis — if any

Goals for working with an herbalist

SECTION III

Health History

A portrait of the terrain.

Current Medical Conditions

Past Illnesses · Surgeries · Hospitalizations

Family Health History

Allergies — foods, medications, plants

SECTION IV

Medications & Supplements

What the body is currently receiving.

Prescription Medications — name, dose, frequency

Over-the-Counter Medications

Vitamins, Herbs & Supplements

SECTION V

Lifestyle & Daily Habits

The rhythm of your days.

Occupation

Stress Level — 1 to 10

Sleep — hours per night

Sleep Quality

Good Fair Poor

Exercise — type & frequency

A day on the plate

Breakfast
Lunch
Dinner
Snacks

Water Intake

Caffeine & Alcohol Use

SECTION VI

Digestive Health

The gut as the gate.

Appetite

Low Moderate High

Bowel Movements

Daily Irregular Other

Symptoms

Bloating Gas Belching Constipation Diarrhea Heartburn Reflux / GERD Nausea Vomiting Abdominal pain Cramping Food sensitivities Undigested food in stool Mucus in stool Blood in stool Loss of appetite Sugar cravings History of IBS History of IBD SIBO concerns Candida concerns Parasite concerns H. pylori Gallbladder issues Liver concerns

Additional notes

SECTION VII

Dental Health & Root Canals

The mouth, often overlooked.

How would you describe your dental health?

Excellent Good Fair Poor

Current dental issues

Cavities Gum disease Tooth pain Sensitivity Other

History of dental procedures — check all that apply

Fillings Crowns Extractions Implants Root Canals

If you have had root canals, please specify tooth & approximate date

Symptoms experienced after dental procedures

Chronic fatigue Jaw pain Sinus issues Headaches None Other

Do you have regular dental care?

Yes No

What has your experience been?

Additional notes

SECTION VIII

Reproductive Health

If applicable.

Menstrual Cycle

Regular Irregular

Last Menstrual Period

Symptoms — PMS, pain, etc.

Pregnancy & Birth History

SECTION IX

Mental & Emotional Health

The inner weather.

Symptoms you are currently experiencing

Anxiety Depression Low mood Mood swings Irritability Anger outbursts Panic attacks Racing thoughts Overwhelm Burnout Grief Loneliness Emotional numbness Low motivation Brain fog Difficulty focusing Memory issues Poor sleep quality Nightmares Social withdrawal Obsessive thoughts Compulsive behaviors History of trauma PTSD ADHD tendencies Addictive patterns

Current Mood

History of Anxiety, Depression or Other

Emotional Stressors

What supports you most when you feel off?

SECTION X

Body Systems Review

A gentle survey, head to foot.

General

Fatigue Low energy Fever Chills Night sweats Weight gain Weight loss Cold intolerance Heat intolerance Unexplained thirst

Skin, Hair & Nails

Rashes Dryness Acne Eczema Psoriasis Itching Hives Easy bruising Slow wound healing Hair loss / thinning Brittle nails Ridged nails

Respiratory

Cough Asthma Shortness of breath Wheezing Congestion Chronic sinusitis Post-nasal drip Sore throat Seasonal allergies Mold sensitivity

Cardiovascular

High blood pressure Low blood pressure Palpitations Chest pain / tightness Cold hands / feet Swelling / edema Varicose veins High cholesterol

Musculoskeletal

Joint pain Joint swelling Muscle tension Muscle weakness Cramps / spasms Back pain Neck pain Stiffness Old injury flare-ups

Nervous System

Headaches Migraines Dizziness Vertigo Insomnia Numbness / tingling Tremors Memory issues Brain fog Tinnitus

Digestive

Bloating Gas Reflux / GERD Nausea Constipation Diarrhea Cramping Food sensitivities Liver / gallbladder issues

Urinary

Frequency Urgency Burning / pain Recurrent UTIs Incontinence Kidney stones Waking to urinate

Immune & Lymphatic

Frequent illness Slow recovery Swollen glands Food allergies Environmental allergies Autoimmune condition Chronic inflammation Lyme / tick-borne

Endocrine & Hormonal

Thyroid imbalance Blood sugar swings Energy crashes Adrenal fatigue Low libido Hot flashes Hormonal acne PCOS Endometriosis Infertility concerns

Eyes, Ears, Nose & Throat

Dry eyes Blurred vision Floaters Ear pain / pressure Hearing issues Nosebleeds Loss of smell / taste Mouth ulcers Bleeding gums

Mental & Emotional

Anxiety Depression Mood swings Irritability Panic attacks Overwhelm Brain fog Low motivation Racing thoughts Emotional numbness Grief Trauma history

Anything else you'd like to share

SECTION XI

Herbal & Alternative Medicine

Your history with the plants.

Have you used herbal medicine before?

Yes No

Have you worked with an herbalist or naturopath before?

Yes No

Do you have a specific budget when it comes to supplements, herbs, etc.?

So we can tailor recommendations to what feels sustainable for you.

Any notes on budget or preferences (optional)

SECTION XII

How You Found Us

Where did you hear about Floral Botanical Medicine?

Please select all that apply

Instagram Natural Awakenings Friend or family Word of mouth Google & search Podcast Event or workshop Another practitioner Returning client

If a specific person referred you, who?

Other — please share

Your privacy and confidentiality are a top priority. Everything you share is stored in our own private, secured database and used solely to guide your care. We never sell your information, and we never share it with any third-party marketing, advertising, or data service. It is not sent to any outside form or email service — it comes only to us.

I agree to share accurate health information to the best of my knowledge.

I understand that results vary and no guarantees are made.

Signature

Sign above with your finger, stylus, or mouse.

Date

When you're ready, send your intake through.