The Herbal Helper Form
Please fill out this form as best you can so we can provide you with the most relevant service.
First Name
Last Name
Email
Phone Number
Gender
Male
Female
Age
Share a Picture or Video? (Optional)
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Share a File? (Optional)
Select a File
How would you describe your health?
Why are you interested in our service?
Occupation (This helps us understand your needs better)
Pre-existing Health Conditions?
Medications and/or Supplements (Includes birth control) Please list names and dosage
Seasonal or Food Allergies? Do you take medication for this?
Any additional comments?
What is your height and approximate weight?
Are you pregnant?
Yes
No
Menopause
Male
Do you drink Coffee?
Do you drink alcohol? If history, please add in comments.
often
occassionally
never
Do you use recreational drugs? If history please add in comments.
Yes
No
Do you smoke cigarettes? If history please add in comments.
Yes
No
How would you describe your schedule? How is your work/life balance?
Do you eat breakfast everyday?
Select all those that you eat often (3 or more times weekly)
Dairy
Red Meat
Sugary Foods or Beverages
Salty or Fried Foods
Processed Foods
Select all those that you eat often (3 or more times weekly)
Fruit
Vegetables
Nuts & Seeds
Whole Grains
Lean Meats
Fish
Shelled Beans
Potato
Rice
Favorite Vegetables
Leafy Greens
Broccoli
Corn
Green Beans (technically fruit)
Peas (techincally fruit)
Squashes
Asparagus
Other
Favorite Fruits
Apple
Orange
Pears
Berries
Dry Fruit
Melons
Other
Are you a picky eater? Elaborate as much as possible.
What is your preferred taste?
Sweet
Sour (example pickles or citrus)
Salty
Spicy
Not applicable
How would your bowel movements? Choose all that apply
regular
irregular
frequent urination
diarrhea
constipation
What time do you wake most often?
7 AM or earlier
8 AM
9 AM
10 AM or Later
What time do you go to bed most often?
9 PM or earlier
10 PM
11 PM or Later
Anything you want to comment about your schedule?
How would you describe your skin? Choose all that apply
Dry
Oily
Acne prone
Sensitive
Combination
If you get acne, where is it located?
Have you tried herbs before? Which ones, how often, what type (extract, capsules, etc.)?
Any recurring illnesses?
Any other symptoms you want to address?
Anything you are not open to trying?
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Your Signature
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