Joette's Herbal Apothecary and Spa
Joette Hill, Herbalist, LMT
(Ph)443-360-8534 (Fax) 410-366-1211 • www.joettesherbs.com
New Client Intake Consultation Form
Today’s Date: ______ / ____ / ____
month day year
NAME: _________________ / _______________ / __________
last name first name middle name
ADDRESS: _____________________________ / ________________ / ________
apt #, street #, street name city postal code
BIRTH DATE: _____ / ____ / _____ AGE: _____ OCCUPATION: _____________________
month day year
PHONE: home: ______________ work: _______________ mobile: _________________
FAMILY PHYSICIAN (if any): ____________________ Location: _________________
Do you have any objections to your family physician being contacted about the progress of your
condition? Yes No
How did you hear about this clinic? __________________________________________
Have you ever been treated with Chinese Medicine/Acupuncture?
Yes: when? ______________________________________________ No
Reason for today’s visit (chief complaint(s)):
Your physician’s diagnosis (if any): _______________________________________
Please list any prescription medications and/or over the counter drugs you are currently taking:
Please list any allergies you may have (food, drugs, herbal, environmental) if any:
Are you a vegetarian? Yes No
Are you pregnant or is there a chance you may be pregnant? Yes No
Do you wear a pacemaker? Yes No
Have a serious heart or lung condition? Yes No
Are you a hemophiliac? Yes No
Do you have epilepsy? Yes No
Are you HIV positive? Yes No
Do you have any surgeries scheduled? Yes No
Are you taking anticoagulant medications? Yes No
Have you ever been hospitalized and/or treated for any infectious or serious diseases and what
kind of diseases? ______________________________________________________________
Please list any herbal medicines and/or supplements you are taking:
Please circle if you use any of the following: Cigarettes / Alcohol / Drugs
What goal(s) do you have for your health care at this time?
Relief of present symptoms Development of optimum health potential Long term health care
(Please complete the following section - For Female Patients only)
Age of your very first period? _________ years old
Date of last period (when menstruation arrived)? __________
Cycle length (i.e...28 days): ___________ Is your cycle regular? Yes No
Describe your flow: Heavy Light Average
Color of your flow: pink bright-red dark-red purple brown black
Do you have large clots in menstrual blood? Yes No
Do you have cramps during menstruation? Yes No
Do you have spotting outside of your menstrual flow? Yes No
Do you have any of the following Pre-menstrual symptoms?
Irritability & mood swings
Please list any other menstrual symptoms you may have: ________________________________
Please check off any of the following symptoms you are experiencing:
Eyes, Ears, Head, Neck
_ Dizziness _____ Tongue/ mouth ulcers
Enlarged lymph glands
Ringing in the ears (tinnitus)
Poor night vision
Red, burning, itchy eyes
Coughing up blood
Coughing up phlegm
Shortness of breath
Frequent colds & flu’s
Nose, Throat, Mouth
Hay fever allergies
Bitter taste in mouth
Muscles & Joints
Weakness in muscles
Heaviness in body
Backache or knee pain
Pain/itching of genitalia
Frequent or urgent urination
Blood in urine
Unable to hold urine
Wake up to urinate
Decreased sex drive
Nausea and/or vomiting
Blood and/or mucus in stools
Intestinal pain or cramping
Patient Consent Form and Appointment Policy
While Therapeutic Herbs, Cupping, Massage Therapy, and other treatments provided by this clinic have proven to be highly effective in correcting conditions and maintaining overall well-being, practitioners are required to advise patients that there may be some risks. Although practitioners cannot anticipate all the possible risks and complications that may arise with each individual case, you should be aware that the following side effects can occur. If there are any particular risks that apply in your case, your practitioner will discuss these with you.
What are the possible side effects of Therapeutic Herbs or Massage Therapy?
Drowsiness can occur in a small number of patients.
Minor bruising can occur from cuppling treatments.
In less than 3% of patients, symptoms may become worse before they improve for 1-2 days following treatment.
This is usually a good sign. Please advise your therapist if worsening of symptoms continues for more than 2
Fainting can occur in certain patients, but this is very rare.
Statement of Consent
I confirm that I have read and understood the above information, and I consent to having treatments and procedures from this clinic. I have read the possible risks of treatment outlined above, but do not expect the practitioner to be able to anticipate and explain all possible risks and complications of treatment. I also understand that I can refuse treatment at any time. I wish to rely on my practitioner to exercise judgment during the course of treatment which, based upon the facts then known, is in my best interests. I understand the practitioner may review my medical records and lab reports, but all my records will be kept confidential and will not be released without my written consent.
The information received and collected about our clients/patients from their visit to Joette's Herbal Apothecary & Spa of Baltimore is strictly private and confidential. It is used and viewed only by the healthcare professionals and staff employed by Joette's Herbal Apothecary & Spa of Baltimore, unless, in the best interest of the client/patient, a practitioner determines that there is a need to communicate with another person or healthcare professional outside Joette's Herbal Apothecary & Spa of Baltimore (also, Joette's Herbal Apothecary & Spa of Baltimore will not give, share, sell or transfer any personal information to a third party unless required by law). Under absolutely no circumstances would this communication happen without the signed consent of the client/patient.
Many of our clients are pleased to find out that we are usually on time. This is because your treatment has been reserved for you, whereas most medical offices overbook by appointing several patients at the same time. That kind of scheduling provides the practitioner with a steady flow of patients but does not respect the patient’s time.
Occasionally, there is a problem with patients who are not used to staying on schedule themselves. With that in mind, if you are going to be more than 15 minutes late, please call to confirm availability. A 24-hour notice for cancelled or rescheduled appointments is necessary in order to avoid a cancellation fee of $30-$60. This allows us time to schedule another patient that would also benefit from treatment. This appointment policy allows us to develop a mutual consideration and respect for our time and yours. By voluntarily signing below, I show that I have read this consent to treatment, and have been told about the risks and benefits of treatments provided by this clinic. I intend this consent form to cover the entire course of treatment for my present condition and further conditions for which I seek treatment. I have read this statement and fully understand it.
Print Name: _________________________________________________________________________________