Consultation record - Herbal Enrichments

Name *

First

Last
Today's Date / Time *
Phone number *
Email Address *
Date of birth *
Age *
What's your gender? *
Education *

High School College Never graduate school Some schooling
Main reason for this consultation? *
How long have you had these conditions? *
Are there any life changes that could possible be a cause for these conditions? *
Are you currently receiving care from any other health professional?
Please list all known allergies. This is very important *
Please list all your health conditions including infections *
Are you currently taking any medications, prescription, herbs, supplements or otherwise? Please list them below *
Have you listed all your health conditions, known allergies, drugs, prescriptions, supplements, herbs, and any other medications above? *

Yes No
Are you pregnant? *
Do you smoke? *

Yes No
How long have you been smoking and the amount per day?
Do you use recreational drugs? *

Yes No
Do you drink alcohol? *

Yes No
How long have you been drinking and the amount per day?
Please list your daily water intake? *
How often you exercise and for how long? *
Sleep *

Little to no sleep Less than 7 hours 7 hours or more Wake up during the night No issue
Please rate your overall energy level *

Excellent Good Ok Poor Terrible
SKIN & HAIR. Select all that applies. *

NONE Rashes Itching Dandruff Change in skin texture Poor healing sores Eczema Psoriasis Hair loss Hives Pimples Moles Other Burns
SKIN & HAIR others please list.
HEAD, EYES, EARS, NOSE, & THROAT. Please select all that applies. *

NONE Poor vision Earaches Ringing in ears Cold sores Facial pain Sinus congestion Ear infections Spots in front of eyes Cataracts Blurred vision Sore throat Grinding teeth Clicking jaw Mucous in throat Dizziness Glaucoma Poor hearing Canker sores Nose bleeds Eye pain Swollen glands Frequent colds Others
HEAD, EYES, EARS, NOSE & THROAT others please list.
CARDIOVASCULAR. Please select all that applies. *

NONE High blood pressure Irregular heart beat Cold hands or feet Low blood pressure Fainting Chest pain Palpitations Other?
CARDIOVASCULAR others please list.
RESPIRATORY *

NONE Cough Coughing blood Bronchitis Pneumonia Asthma Pain on breathing Shortness of breath Difficulty breathing Production of phlegm
RESPIRATORY others please list.
GASTROINTESTINAL *

NONE Nausea Constipation Abdominal pain Blood in stools Hemorrhoids Food cravings Difficulty swallowing Vomiting Black stools Indigestion Mucous in stools Gas Poor appetite Diarrhea Bad breath Heartburn Rectal pain Option-18 Bloating Food allergies
GASTROINTESTINAL others please list.
Amount of daily bowel movements? *
URINARY *

NONE Painful urination Urinary urgency Incontinence Frequent urination Kidney stones Inability to hold urine Blood in urine Irregular flow Decreased flow Difficulty starting/ stopping slow
MUSCULOSKELTEAL *

NONE Neck Back pain Muscle pain Muscle weakness Stiffness Reduced range motion Other
Do you see a chiropractor or massage therapist? (name)
REPRODUCTIVE *

NONE Heavy bleeding Pain with intercourse Unusual bleeding Cramps Discharges Irregular cycles Breast lumps Clots PMS
What age your first menses?
Length of cycle?
PMS symptoms if any?
NEUROPSYCHOLOGICAL *

NONE Poor sleep Depression Seizures Headaches Lack of coordination Poor memory Irritability High stress levels Difficult concentrating Loss of balance Numbness Anxiety Migraine Spacey/ foggy feeling
General *

NONE Fatigue Night sweats Slow metabolism Fevers Excessive thirst Intolerance to heat/ cold Chills Sudden energy drops
Any recent bloodwork? *
If you would like to share your bloodwork with us please do via this link
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Do you want us to pray with you? *

Yes No
Select if you fully agree to the above and below statements. *

I understand that herbal and nutritional counseling is not meant to be or intended to be any type of treatment, prescription or diagnosis for any disease, whether physical disease or mental disease. I also understand that herbal and nutritional counseling is not a substitute for standard medical care by a licensed doctor. I also understand that Oneil Brown has over one year experience in the states of Texas as an herbalist and that he is NOT a licensed health care provider. I understand that Oneil Brown’s experience includes herbal consultation and botanical studies and medicine making. I’m also a board-certified Master Herbalist by the ANMCB – American Naturopathic Medical Certified Board. I request that Oneil Brown assist me by co-evaluating my current state of well-being, educating me on the use of herbs and nutrition and helping me create an herbal program to improve my general state of health. I understand that a sound approach to good health includes diet, lifestyle and can also be assisted by herbs that have medicinal effects. I also understand that if I do not feel comfortable – physically, emotionally or otherwise - with any of the herbs, education or help I am offered, I should not pursue it and should always consult a licensed doctor for treatment or diagnosis of any health condition. By clicking fully agree you agree to all the terms, disclaimers and that all of the above information you entered are correct.

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