Herbal Hygienist
Dabney Vaccaro, BS, RDH,
Clinical Herbalist & Health Coach
540.908.5404
Health History
PERSONAL INFORMATION
Name: ________________________________________________
Email: ________________________
How often do you check email? _________________________
Mobile Phone Number: _______________________________
Age: ______ Height: _______________
Birthdate: _______________________
Place of birth: ___________________________________________________________
Current Weight: __________
Weight 6 Months Ago: _________
One Year Ago: _______________
Would you like your weight to be different? ____________
If so, what? _______________________
SOCIAL INFORMATION
Relationship status: _____________________________________________________________
Where do you currently live? _______________________________________________________________
Children: _______________________________________________________________________________
Pets: __________________________________________________________________________________
Occupation: _______________________________ How many hours do your work per week? ________
HEALTH INFORMATION
Please list your main health concerns: __________________________________________________________
Other concerns and/or goals? _______________________________________________________________
At what point in your life did you feel your best? __________________________________________________
How is the health of your mother? _____________________________________________________________
How is the health of your father? ______________________________________________________________
What is your ancestry? ______________________________________ What is your blood type? _________
How is your sleep? __________________________________________________________________________
How many hours do you sleep? _______ Do you wake up at night? ___________ Why? ____________
_______________________________________________________________
Any pain, stiffness, or swelling? _______________________________________________________________
Any accidents/surgeries? Please explain: _______________________________________________________
Constipation/Diarrhea/Gas? __________________________________________________________________
Allergies or sensitivities? Please explain: ________________________________________________________
WOMEN’S HEALTH
Is your menstrual cycle regular? _________ How many days? __________ How frequent? _______________
Is your flow— light/normal/heavy Painful? _________
Have you reached menopause? _______________________
Birth control history: ____________________________________________________________
MEDICAL INFORMATION
Medication list including supplements: _________________________________________________________
Medical diagnosis from physician: _____________________________________________________________
Do you see other therapists including healers? ____________ Please list: _____________________________
What role do sports and exercise play in your life? ________________________________________________
FOOD INFORMATION
What foods did you eat often as a child?
Breakfast
Lunch _________________________________________
Dinner _________________________________________
Snacks _________________________________________
Liqui. _________________________________________
What foods do you like these days?
Breakfast ________________________________________
Lunch ________________________________________
Dinner ________________________________________
Snacks ________________________________________
Liquid ________________________________________
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? ____________
Do you cook? ______________ Who in your home is the primary meal planner? ___________________
What percentage of your food is home-cooked? __________________________________________________
Where do you get the rest from? ______________________________________________________________
Do you crave sugar, coffee, cigarettes, or have any major addictions? _________________________________
The most important think I should do to improve my health is: ____________________________________________________________
ADDITIONAL COMMENTS:
Anything else you would like to share?
__________________________________________________________
Herbal Hygienist
ASSUMPTION OF RISK, RELEASE, COVENANT NOT TO SUE AND AGREEMENT TO HOLD HARMLESS
The undersigned hereby accepts and assumes all risk and liability associated with my taking the formula or tincture provided to me by my attending herbalist and Herbal Hygienist and its Clinic.
The undersigned hereby assumes any risk of an injury to myself or others in my care. The undersigned hereby releases, waives and discharges the attending herbalist and Herbal Hygienist. Plant from any and all liability from any loss or damage, and claims or damages resulting therefrom, on account of injury to persons or property, even injury resulting in death, whether caused by the attending herbalist and Wild Herbals, LLC, negligence or otherwise.
The undersigned will indemnify and hold harmless the attending herbalist and Herbal Hygienist from any loss, liability, damage, expense or cost, whether caused by the attending herbalist and Herbal Hygienist negligence or otherwise, and whether claimed by or through the undersigned or others, including costs and attorney’s fees incurred or suffered by reason of any claims, demands, actions, or suits which may be filed or claimed against the attending herbalist and Herbal Hygienist.
The undersigned covenants not to sue the attending herbalist and Herbal Hygienist and will not individually, or for others, or on behalf of minors, bring or prosecute, or in any way aid in the institution or prosecution of any claim or suit against the attending herbalist and/or Herbal Hygienist.
References to the undersigned shall also include and obligate the undersigned’s spouse, family, children, guests, invitees, heirs, and assigns, and all persons claiming by or through the undersigned. References to Herbal Hygienist, shall benefit Herbal Hygienist, and the Herbal Hygienist clinic its lessor, officers, employees, agents, successors and assigns.
Signed this _______ day of __________________, 20______.
Signature: ______________________________________________________