Tosha Vidrine
Practicing Community Herbalist

 

*Please print and fill out prior to your first appointment.

•HERBAL CONSULTATIONS, Coaching & REMEDIES•

Herbal Intake Form
Name:________________________________________________________________________

Address: ______________________________________________________________________ ______________________________________________________________________________

Telephone: (w)____________________________ (h) __________________________________

Best time(s) to call:______________________________________________________________ Email:_________________________________________

Preferred form of contact: __________ Occupation: _________________________________________ Gender (m/f): _________ Age: _______ Height: _______ Weight: _______lbs

Birth date & Time if known ________________________ Zodiac Sign:________

 

Who do you share your home with: ________________________________________________

Number of children: ___________ Age(s): _________________________________________

Please list all physicians and other healthcare providers or consultants (such as Therapist, Acupuncturist, massage therapist, etc) you see on a regular basis:
Name Location Type of Service
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Would you like me to contact them regarding your health plan with me?___________________
Family Medical History:
Please describe any relevant or major health-related issues:

Father: _______________________________________________________________________

 Mother: _______________________________________________________________________ Maternal Grandmother: __________________________________________________________ Maternal Grandfather: ___________________________________________________________

Paternal Grandmother: __________________________________________________________

Paternal Grandfather: ___________________________________________________________

 Other family members with pertinent issues, or recurring family health trends: _____________________________________________________________________________ _____________________________________________________________________________

PRESENT HEALTH STATUS
Do you currently smoke tobacco (y/n)? _______

 If so, how many cigarettes/day? _______
If not, have you ever been a smoker in the past (y/n)? _______
For how many years did you smoke? _______When did you quit? _______
Do you currently drink alcohol (y/n)? _______ If so, list type, quantity, and frequency: _____________________________________________________________________________

Did you consume alcohol in the past (y/n)? ______ When did you quit alcohol? _____________ If so list type, quantity and frequency:_______________________________________________

List form and frequency of any regular exercise: ______________________________________

How is your digestive system overall, do you experience indigestion, gas, constipation, diarrhea, bloating or other? _____________________________________________________________ _____________________________________________________________________________

How often do you have a bowel movement? ________________________________________

How often do you urinate and what is the character of your urine, i.e., light, dark, strong odor?
____________________________________________________________________________
Present Health Status 1-10
Chronic Conditions?
Sex drive 1-10
Addictions? Please list and explain
Vices
Anger 1-10
Any changes that you would like to make in your current life or routine?
Do you dance, sing, play an instrument, make art, or create?
Hobbies:
Interests:
Unusual Interests:
Reoccurring infections:
Religion or Spiritual Orientation?
Any other concerns not mentioned?
Financial Health 1-10
Worthy goals?
How much time do you spend online daily?
Social Media?
Reading?
Browsing?
Etc.?
Check each column where symptoms apply and elaborate in space provided below if necessary. Please indicate with a √ any experiences below that you sometimes experience; two checks √√ for those which occur often; and use three checks √√√ for those which are a major concern.
Cardiovascular
_____High Blood Pressure
_____Low Blood Pressure
_____Pain in Heart
_____Poor Circulation/cold extremities _____Swelling in Ankles/joint _____Previous heart stroke/murmur _____High Cholesterol
Muscles/Joints _____Backache/upper or lower _____Broken Bones _____Mobility Restriction _____Arthritis/Bursitis
Eyes, Ears, Nose, and Throat _____Asthma
_____Ear Aches
_____Eye Pains, Dry/Wet _____Failing vision
_____Hay Fever
_____Sinus Infection _____Sinus Congestion _____Sore Throat _____Tonsils
_____Hearing Loss/Ringing Ears
Urinary/Kidney _____Excessive Urination _____Water Retention _____Burning Urine _____Kidney Stones _____Lower Back Pain _____Dark circles under eyes _____Itchy Ears/eyes _____Emotional Insecurity
Skin
_____Boils _____Bruises _____Dryness _____Itching _____Varicose Veins ____Skin eruptions
Respiratory
_____Chest Pain _____Difficulty breathing _____Cough _____Tuberculosis _____Congestion
Gastro-Intestinal _____Belching _____Colitis _____Constipation _____Abdominal Pain _____Liver Problems _____Gall Stones _____Ulcers _____Indigestion
Sleeping Patterns
_____Insomnia
_____Waking in the night _____Nite sweats
_____Restless sleep
_____Wake up tired _____Difficulty falling back to sleep
Miscellaneous
_____Usually feel Hot/Warm _____Usually feel Cold/Cool
Do you have headaches?______How often?______________What are they like?_____________ ______________________________________________________________________________ Do you know what causes them?___________________________________________________


Common Physical Activities
__Desk Sitting (how long) __Sitting in a car (how Long) __Calisthenics
__Swimming
__Walking
__Tai Chi
__Bike Riding
__Tennis __Other_______________________
__Standing (how long?) __Jogging/Running __Aerobics
__Weight Lifting __Yoga
__Hiking __Horseback Riding __ BendingLifting
Do any of the conditions above aggravate a current health condition?
Have you had any operations? ____What year? _______________________________________ Any major injuries/accidents?____ What and when? ___________________________________ Any major illness or hospitalizations? ___What and when? ______________________________
DIETARY INFORMATION
Please check each item listed below if it is included in your daily - or usual - diet (mark D=daily,
W=weekly, M=monthly, N=never):
___Red Meat ___Fish
___Poultry
___Fruits ___Vegetables ___Raw Foods ___Grains
___Nuts
___Seeds ___Fermented Foods
___Butter ___Milk ___Cheese ___Yogurt ___Sugar ___Honey ___Baked Goods ___Deserts ___Chips ___Crackers
___Candy bars/chocolate ___Coffee
___Black Tea
___Herbal Tea ___Alcohol
___Vitamins
___Protein Supplements ___Food Supplements ___Processed foods/snacks


Dietary Information
Describe below your typical meals. Please be as specific as possible. For example, Instead of "oil" list type of oil, such as olive, corn, etc. Instead of "bread" list whether white or whole grain, etc. Instead of "vegetables" list type of vegetable, how prepared, canned, frozen, or fresh,
etc. Please include beverages, type and quantity (two cups of coffee, one glass of orange juice, etc.)
What’s a good day of eating like?
Breakfast: _____________________________________________________________________
_____________________________________________________________________________
A.M. snack(s): _________________________________________________________________ Lunch: _______________________________________________________________________ _____________________________________________________________________________ P.M. snack(s): _________________________________________________________________ Dinner: _______________________________________________________________________ _____________________________________________________________________________ Evening snack(s): _______________________________________________________________ Daily water consumption (# glasses/quantity/day): ______________
What’s a bad day of eating like (meals on the run, etc):
Breakfast: _____________________________________________________________________ _____________________________________________________________________________ A.M. snack(s): _________________________________________________________________ Lunch: _______________________________________________________________________ _____________________________________________________________________________ P.M. snack(s): _________________________________________________________________ Dinner: _______________________________________________________________________ _____________________________________________________________________________


Evening snack(s): _______________________________________________________________ Daily water consumption (# glasses/quantity/day): ______________
How many times a week do you have a good day___________Bad day___________of eating? Please list any known food allergies/sensitivities (attach additional sheets if needed):
Food Describe Reaction _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
If everything was good for you, what would you want to eat (What do you crave)?___________ _____________________________________________________________________________

Have you ever had herb tea?____________
Current State of Emotions and Feelings
Please take a moment to answer the following questions:
Are you able to express your feelings and emotions? _________________________________

Is there an excess of stress in your life? ___________________________________________

What is causing the stress?______________________________________________________

Are you satisfied with your job? __________________________________________________

 If in a relationship, are you satisfied with it?_________________________________________

 If there is one thing in your life you would like to change right now, what is it?_____________ ____________________________________________________________________________

Can you change it?_____________________________________________________________

Are you a "nervous type" person? _________________________________________________

What are the things that make you most nervous?____________________________________

Are you a perfectionist? Consider yourself OCD, bipolar or depressed etc.______________________________________

Do you sleep well?________

How long each night?____________________________________

 Do you nap?_______ How long and often?_________________________________________
Any aggressiveness?
How would you describe yourself?



Do you dream?________

Do you remember your dreams?______________________________

Are you satisfied with your general energy level?______________________________________

 Do you often feel exhausted and fatigued?________________________________________
Is it easy to wake up in the morning?_____________________________________________

Which of these feelings dominate in your life:
joy happiness anger sadness fear sympathy worry depression If you were to choose two Emotions, which seem predominant in your life they would be_______________________and_______________________
Please indicate approximate dates and describe the nature of any traumatic experiences you have had in the past 10 years (divorce, loss of lover, loss of job, change of residents, injury, death, etc.)
Year Event _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
Name one thing in life that you do that is really good for you:____________________________ ______________________________________________________________________________

Name one thing you know you should be doing but don’t:_______________________________ ______________________________________________________________________________What are your passions and interests?_______________________________________________ ______________________________________________________________________________


What do you do for fun?__________________________________________________________
Supplements and Medications
List all herbs, vitamins, and dietary supplements you currently take, Citing brand name whenever possible (please bring all your supplement bottles with you for your appointment): Use additional paper if needed
supplement dosage _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
List all medications you are currently taking and what they are taken for (including aspirin, antacids, etc.), indicating whether they are over the counter (OTC) or prescription (P):
Use additional additional paper if needed
Name of Product/used for OTC or P? Dosage Frequency (#/day) _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Do you use any other drugs? Circle any that apply:
marijuana, pills, mushrooms, ecstasy,cocaine LSD, heroin other:_____________ Have you used any drugs in the past? Circle any that apply:
marijuana mushrooms ecstasy cocaine LSD heroin other:_____________ List all medications, herbs, etc., to which you have a known allergy: _____________________________________________________________________________ What are the areas of current complaint that you would like to address with an herbal program? _____________________________________________________________________________


STATEMENT OF UNDERSTANDING
The human body has the innate power to heal itself. Without this power to self-heal, even the most advanced medications and surgical procedures would ultimately fail. The role of the herbalist in this healing process is to consider the client as a whole person and to consult with the client concerning changes in lifestyle, diet, and supplementation of herbs and/or vitamins to foster an increased state of balance and health, thus maximizing the body's self-healing capabilities.
I practice nutrition related assessment, diagnosis, and therapeutic methods based on the healing system. This scope of practice includes dietary assessment, dietary changes, physical diagnosis related to nutrition (including pulse, palpation, tongue, and observation) interpretation of laboratory values relating to nutrition, dietary counseling, reviewing medical records, recommending diet therapies, recommending nutritional supplements when indicated, and identifying proper treatment strategies.
My approach is to combine numerous alternative healing methods together with the latest scientific findings and clinical practices. Nutrition and herbs are my primary specialty and represent my area of expertise. The degree of incorporation of these systems will vary from case to case. The basic principle is to help the body’s natural capacity to restore balance, health, and harmony. Assessments are focused on identifying patterns and imbalances. Depending on the patient’s wishes, recommendations may incorporate nutrition, herbs, supplements, counseling and /or coaching, exercises and lifestyle. Recommendations may be use to instill physical, emotional, mental, and/or spiritual balance.
I am NOT a Medical Doctor nor do I practice western medical assessment, diagnosis, or treatment. I do not claim to cure disease. Nor do I give advice about pharmaceuticals and medications at any time. I have no objections to my clients being seen or evaluated by their own medical doctor. If you have any questions or concerns about your condition, I highly recommend you discuss it with your physician. I am willing to work as part of a health care team including physicians and other health care providers. If you would like me to work with your physician, please inform you physician also of this wish. I also recommend you inquire and explore any recommendations I provide with any professionals in health care.
Further, I have herbal/nutritional apothecary in the shop & at home. I sell many herbal products and some food products for a profit. I dispense them here as a convenience and to ensure patients are receiving the specific, individualized herbal formula they need. I also use them to create customized herbal formulas to fit the exact profile for what I feel clients need. Clients are not obligated to buy any products here. I encourage clients to buy any supplements wherever it is most convenient for them. The recommended nutritional/herbal supplements are not a replacement for the medications prescribed by your Medical Doctor.
Tosha Vidrine
Please sign below once you have read and understood the above statement:


Name (print)___________________________________________ Date: ___________________ Signature______________________________________________________________________
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Mailing Address (with Zip): _______________________________________________________ _____________________________________________________________________________ Phone Number:________________________ Email:___________________________________ Referral Source:________________________________________________________________
Miles Blair Salon LLC