Herbal Medicine Intake Form

Client Intake Form -- HERBAL mini CONSULT

TODAY'S Date

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone number

Age

Gender

Current Health Snapshot

How would you describe your general health at the moment?

What are your main health goals or concerns?

Are you currently under the care of any other health practitioners? (Doctors, specialists, therapists, etc.)

Do you have any allergies (to medicines, herbs, foods, or anything else)

Are you allergic to any medications?

Yes

If so, which?

Do you take any prescribed medications?

What current herbs and/or supplements do you take regularly?

Medical & Family History

Do you have any diagnosed health conditions (past or present)?

Have you had any major surgeries or hospitalizations?

Any other relevant health or medical information:

Is there a family history of any major illnesses (e.g. diabetes, heart disease, autoimmune conditions, mental health challenges)?

Lifestyle & Wellbeing

How would you describe your sleep?

How is your digestion?

How is your energy throughout the day?

How would you describe your stress levels? (What are your main sources of stress?)

What do you do for movement or exercise?

Do you smoke, use recreational drugs, or have alcohol/caffeine? (How often?)

For Women (if applicable)

Are you currently pregnant, breastfeeding, or planning to become pregnant?

How are your menstrual cycles?

Herbal & Natural Health

Have you used herbal remedies before?

Are there any herbs, foods, or products you know you react to?

Hopes & Preferences

Are there any particular approaches or remedies you are interested in or would like to avoid?

How would you like to integrate herbal medicine into your life?

Is there anything else you’d like me to know, or any questions you have?

Consent & Confidentiality Statement

I consent to Thrive Therapies using AI tools for these purposes—assisting with communication and administrative tasks related to my intake forms and email/messages, including analysing, organising, and summarising my provided information to help prepare clearer written responses and correspondence. I understand this support is intended to improve efficiency and clarity, and is a helpful assistant and not a replacement for Shanti Smith’s care, professional knowledge, or the Thrive Therapies services I receive, and any information shared is confidential and used only to support my care and wellness journey at Thrive Therapies. If you have any concerns or questions, please let Shanti know.

Informed Consent

I confirm I have shared any important medical information with Shanti Smith of Thrive Therapies.

Any advice or information given by Shanti is for educational purposes only, not diagnosis. I am responsible for my own healthcare choices and decisions.

By signing below, I confirm that I have read and understood these consents. I understand that Thrive Therapies and Shanti Smith are not responsible for outcomes related to any treatments, suggestions, recommendations, or herbal formulas, now or in the future. All information I share will be kept confidential.

This consent form is based on current best practices for holistic therapies in New Zealand.

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