Client Intake Form

Client Intake Form: 

Name:


Age:

Sex:

Height:

Weight:

Blood Pressure:

Heart Rate: If known

Chief Complaint: (things that bother you most or you most want to change, symptoms as specific as possible, how would you rate them on a scale? Describe the type of pain or feeling)

History of Present Illness: (how long have you had? Any particular reasons why symptoms started? Are they on/off or all the time?)

Past medical history: (surgeries, medications, etc)

Current medications/supplements/herbs:

Family History: Any history of diseases?

Social history: (How is your spirit? Good social circle? Relationships, etc)

System/symptom review: (Please list symptoms or diseases based on each body system. You can write NA if nothing is wrong)

Cardiovascular: EyeEarsNoseThroat: Endocrinological: Gastrointestinal: Genito-urinary: Gynecological: Immune System: Musculoskeletal: Respiratory: Psychological:

Skin:

Sleep:

Temperature: (always feel cold or hot?)

Three day diet diary: (if you have time :))

Blood work: (If related to your issue or disease)

Innertwine Herbs is a women owned, small batch, organic herbal medicine business. Our products all use sustainability sourced ingredients & are crafted with intention & Love! The plants offer the true magic & we try to use as much homegrown & locally/ethically harvested herbs as we can. Transparency is a staple in our shop. We also want to “intertwine” people more with the botanical world around us. Spreading knowledge & education about the benefits of plant medicine is important to our mission. Not only do we create holistic products for our community but want to share how natural medicine is obtainable for all of us.

We create the majority of our products using herbs grown or foraged here locally. All ingredients not homegrown are organic & ethically sourced. The quality of the products we provide are of utmost importance to us. We are here to provide amazing healing products, information & recipes on how to add herbs to your lifestyle, as well as connect with other small business to create herbal delights.

Courtney

Courtney is the herbalist, farmer & founder of Innertwine Herbs. She has always felt a connection with the natural world & desires to share it’s healing power with you! She is the initial mind behind all herbal concoctions & grows/creates with intention & healing in mind. She is in her 8th year of studying herbal medicine & is in a continual state of absorbing information! She is expecting her first child this Winter & looks forward to sharing her herbal knowledge with her growing family.

Amber

Amber is an herbalist, gardener & fellow healer. She has few years of studying under her belt & has a fiery passion for growing medicine, along with learning more of what the plants have to offer. She has an affinity for holistic topical preparations & traditional Native American healing. She loves creating herbal products for friends & her family. Amber is a wonderful addition to our team & definitely lights up the room with her positivity & desire to help others.