CLIENT INTAKE FORM

Joette's Herbal Apothecary and Spa

Joette Hill, Herbalist, LMT

(Ph)443-360-8534 (Fax) 410-366-1211 •

______________________________________________________________________________

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: _________________

EMAIL: ______________________

FAMILY PHYSICIAN (if any): ____________________ Location: _________________

Phone: ___________________

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)

Gynecological History

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?

􀀀 Breast tenderness

􀀀 Irritability & mood swings

􀀀 Acne breakouts

􀀀 Headaches

􀀀 Bloating

􀀀 Fatigue

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

􀀀 Fainting

􀀀 Enlarged lymph glands

􀀀 Migraines/headaches

􀀀 Ringing in the ears (tinnitus)

􀀀 Decreased hearing

􀀀 Earaches

􀀀 Blurry vision

􀀀 Spots/floaters

􀀀 Dry eyes

􀀀 Eye pain

􀀀 Poor night vision

􀀀 Red, burning, itchy eyes

􀀀 Other: ____________

Cardiovascular

􀀀 Rapid heartbeat

􀀀 Chest pain/tightness

􀀀 Irregular heartbeat

􀀀 Swollen ankles

􀀀 Poor circulation

􀀀 Other: ____________

Respiratory

􀀀 Chronic cough

􀀀 Coughing up blood

􀀀 Coughing up phlegm

􀀀 Shortness of breath

􀀀 Wheezing/Asthma

􀀀 Frequent colds & flu’s

􀀀 Other: __________

Nose, Throat, Mouth

􀀀 Bleeding gums

􀀀 Sinus infection

􀀀 Hay fever allergies

􀀀 Swollen glands

􀀀 Difficulty swallowing

􀀀 Bitter taste in mouth

􀀀 Tongue/mouth ulcers

􀀀 Nose bleeds

􀀀 Dry mouth/thirst

􀀀 Other: ________

Muscles & Joints

􀀀 Joint pain

􀀀 Body aches/stiffness

􀀀 Weakness in muscles

􀀀 Spinal curvature

􀀀 Numbness/tingling

􀀀 Heaviness in body

􀀀 Backache or knee pain

Other: __________

Genito-Urinary

􀀀 Pain/itching of genitalia

􀀀 Genital lesions/discharge

􀀀 Painful urination

􀀀 Frequent or urgent urination

􀀀 Blood in urine

􀀀 Unable to hold urine

􀀀 Wake up to urinate

􀀀 Bedwetting

􀀀 Decreased sex drive

􀀀 Other: __________

Gastrointestinal

􀀀 Nausea and/or vomiting

􀀀 Acid reflux/heartburn

􀀀 Gas

􀀀 Bloating

􀀀 Bad breath

􀀀 Loose/soft stools

􀀀 Constipation

􀀀 Blood and/or mucus in stools

􀀀 Intestinal pain or cramping

􀀀 Itchy anus

􀀀 Burning anus

􀀀 Anal fissures

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

days.

 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.

Appointment Policy

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: _________________________________________________________________________________

Signature: __________________________________________________________________________________

Date: ________________________________________________

J Herbal Apothecary