Herbalist Services Agreement Full Name Preferred Name/Nick Name Date of Birth Current Occupation Lifestyle/Hobbies Current Health Status How would you rate your overall health? Excellent Good Fair Poor Please list any current health conditions or diagnoses: Are you currently taking any medications? Yes No If yes, please list: Have you had any major illnesses or surgeries in the past? Yes No if yes, please specify: Do you have any known allergies? Yes No if yes, please specify: How often do you exercies? Daily Weekly Monthly Rarely Do you smoke? Yes No Do you consume alcohol?? Yes No How would you describe your diet? How much water do you drink daily? What are your primary health goals? What specific outcomes are you hoping to achieve through herbal treatment? Have you tried any other treatments for your current health conditions? Yes No if yes, please specify: Send
