Herb Intake Template Start - Copy

8/17/2019 Herb Intake Template Start - Copy

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P.O. Box 532-Yermo Ca-92398

760-254-3273

Danny L. Abaldo .!.

!erbal "n#a$e

#r%#&andmer'ym(n()#r(e)*l(+e.'om

Cl(en#) ,ame

Addre))

P&one

ma(l

Da#e o/ B(r#&

oday1) Da#e

"n)#r%'#(on) /or yo%r (r)# !erbal Con)%l#a#(on&an$ yo% /or (+(n #&o%&#/%l 'on)(dera#(on a) yo% 'omle#e #&e en'lo)ed ,e Cl(en#

%e)#(onna(re. Yo% (ll &a+e amle oor#%n(#y #o addre)) any 'on'ern) #&a# re%(re more de#a(

d%r(n yo%r ao(n#men# (#& Danny

e%(red /or yo%r /(r)# +()(#

Comle#ed ,e Cl(en# %e)#(onna(re : Paeror$

lea)e al)o br(n #&e /ollo(n

Any lab); blood #e)#) or o#&er er#(nen# med('al (n/orma#(on yo% #&(n$ may be &el/%l.

"/ yo% are #a$(n any &arma'e%#('al); o+er-#&e-'o%n#er dr%); &erb); and<or )%lemen#); lea

br(n #&em (n #&e(r or((nal 'on#a(ner) )o yo%r ra'#(#(oner 'an be )%re #o )ee &a# (nred(en#) an

amo%n#) are (n #&e rod%'#).

l(en# 'on/(den#(al(#y (ll be ob)er+ed %nder all '(r'%m)#an'e).

,e Cl(en# %e)#(onna(re

l(en# 'on/(den#(al(#y (ll be ma(n#a(ned a# all #(me). &e (n/orma#(on ro+(ded on #&()

%e)#(onna(re may only be d()'lo)ed

(#& #&e exre)) r(##en 'on)en# o/ #&e (nd(+(d%al named &ere(n or; (/ %nder #&e ae o/ =8; &() or &er l



%ard(an.

lea)e allo 30-45 m(n%#e) #o 'omle#e #&() %e)#(onna(re. Plea)e an)er #&e %e)#(on) belo a)

&oro%&ly a) o))(ble )o #&a# " may ma$e #&e be)# o))(ble 'l(n('al a))e))men# and de+elo a

eal()#(' and or$able lan /or )%or#(n yo% (n rea'&(n yo%r &eal#& oal). Yo%r an)er) #o

er)onal %e)#(on) )%'& a) rela#(on)&( )#a#%); rel((on; e#'; are (mor#an# a) #&ey ro+(de

el/%l 'on#ex# /or e)#abl()&(n a rod%'#(+e ar#ner)&( (#& yo%. &a# )a(d; lea)e an)er only

&e %e)#(on) yo% are 'om/or#able an)er(n.

L()# any and all Per)e'%#(on Dr%) yo% are '%rren#ly #a$(n

L()# any OC1) yo% are '%rren#ly #a$(n

L()# any !erb) and >%lemen#) yo% are on

ed('al "n/orma#(on

Are yo% %nder a med('al do'#or?) 'are /or yo%r 'ond(#(on@ "/ )o; &a# are yo% be(n #rea#ed /or@

. Are yo% '%rren#ly #a$(n any re)'r(#(on or o+er-#&e-'o%n#er

dr%)@ "/ )o; lea)e l()# ea'& dr% and &a# (# () /or.



!a+e yo% been d(ano)ed by a l('en)ed &y)('(an (#& any o/ #&e /ollo(n@ C&e'$ all #&a# aly.

A"D>

An(na

Ar#&r(#() &e%ma#o(d

Ar#&r(#() O)#eo

Arr&y#&m(a (rre%lar &ear# bea#

A)#&maA##en#(on De/('(en# D()order

ADD<AD!D

A%#o(mm%ne D()order); >e'(/y

e'(/(' >ym#om)

C&e'$ any o/ #&e /ollo(n emo#(on) yo% /(nd (# d(//('%l# #o deal (#&; e(#&er (n yo%r)el/ or o#&er).

mo#(onAner

"rr(#ab(l(#y

r%)#ra#(on

Anx(e#y

ear

>adne))

Dere))(on

x'(#emen#

La%&#er

La'$ o/ en#&%)(a)mLa'$ o/ oy

Eorry

D(e)#(+e; L(+er and "n#e)#(nal >ym#om). C&e'$ all #&a# aly.

Abdom(nal a(n or d()'om/or#

A'(d (nd(e)#(on; &ear#b%rn or a'(d re/l%x

Bad brea#&

Bloa#(n; bel'&(n or (n#e)#(nal a)

Con)#(a#(on boel mo+emen#) le)) #&an on'e er

dayCra+(n) /or )%ary /ood)

D(arr&ea or loo)e )#ool)

ood aller(e); )e'(/y /ood) #&a# (+e yo% roblem)

e)(ra#ory >y)#em >ym#om). C&e'$ all #&a# aly.

C&ron(' or /re%en# 'o%&

Cold )ore)

x'e)) m%'%) rod%'#(on

re%en# (n/e'#(on)

!ay-/e+er and re)(ra#ory aller(e)



C(r'%la#ory >y)#em >ym#om). C&e'$ all #&a# aly.

Anem(a

C&e)# a(n

Cold &and) and /ee#

am(ly &()#ory o/ &ear# d()ea)e

F(n(+(#() or %m d()ea)e

!ear# al(#a#(on)

!(3& blood 4re))%re; )4e'(/y blood 4re))%re n%mber)-

r(nary and l%(d >y)#em >ym#om). C&e'$ all #&a# aly.

Bladder (n/e'#(on)

Blood (n #&e %r(ne

B%rn(n or a(n/%l %r(na#(on

D(//('%l#y )#ar#(n %r(na#(on

x'e))(+e er)(ra#(on

re%en# ale %r(ne

re%en# %r(na#(on

!()#ory o/ $(dney )#one)

❑ ,(&# )ea#)

❑ Pa(n (n #&e m(d #o lo ba'$

❑ P%//(ne)) %nder eye)

❑ >'an#; dar$ %r(ne

❑ Gr(nary (n'on#(nen'e dr(bbl(n

❑ Gr(nary #ra'# (n/e'#(on) G")

❑ Ea#er re#en#(on or edema

❑ >ollen lym& node)

Fland%lar >y)#em >ym#om). C&e'$ all #&a# aly.

B%rn(n )en)a#(on) (n &and) and /ee#

Cold &and) and /ee#

Dar$ '(r'le) %nder eye)

Dry )$(n

x'e)) e(&#

x'e)) e(&# aro%nd #&e abdomen

a#(%e (n #&e a/#ernoon)a#(%e; '&ron(' or ex'e))(+e

eel(n '&ron('ally )#re))ed

eel(n ex&a%)#ed; Hb%rned-o%#I

re%en# #&(r)#

ale) Only

D(//('%l#y %r(na#(on

re'#(le dy)/%n'#(on

"n/er#(l(#y

La'$ o/ )ex dr(+e

emale) Only

Cra+(n) /or '&o'ola#e (#& er(od)

Dere))(on (#& er(od)dema or bloa#(n a))o'(a#ed (#& er(od)

!ea+y men)#r%al bleed(n

!o# /la)&e) and<or n(&# )ea#)

"n/er#(l(#y

"rr(#ab(l(#y (#& er(od)

❑ La'$ o/ )ex%al de)(re

❑ !a(r lo)) or #&(nn(n

❑ La'$ o/ )#am(na

❑ Lo)) o/ )&or#-#erm memory

❑ Lo body #emera#%re; ea)(ly '&(lled

❑ en#al )l%()&ne)); Hbra(n /oI

❑ood )(n)

❑ %ddled #&(n$(n; 'on/%)(on

❑ e)#le)) d()#%rbed )lee

❑ e)#le)) dream) or n(&#mare)

❑ Ea$(n % a# n(&# %nable #o o ba'$ #o )lee

❑ Ea$(n % /re%en#ly a# n(&#

❑ Lo)) o/ )el/-'on/(den'e and dr(+e

❑ ,(&##(me %r(na#(on

❑ Pro)#a#e roblem)❑ Gr(na#(n a# n(&#

❑ en)#r%al 'ram)

❑ ,%r)(n '%rren#ly

❑ Pa(n/%l men)#r%a#(on

❑ P>

❑ Po)#-menoa%)al

❑ Prenan# '%rren#ly

❑ Ja(nal d()'&are



Ja(nal dryne))

,er+o%) >y)#em >ym#om). C&e'$ all #&a# aly.

Ab)en#-m(ndedne))

Al'o&ol()m

Anx(e#y; ner+o%)ne))

C&ron(' m%)'le #en)(on

D(//('%l#y e##(n #o )lee

D(KK(ne)) or l(&# &eadedne)).

x'(#ab(l(#y; d(//('%l#y relax(n

eel(n dere))ed or d()'o%raed

!eada'&e)

❑ en)(on &eada'&e) (#& #(&#; 'on)#r('#ed /eel(n

>#r%'#%ral >y)#em >ym#om). C&e'$ all #&a# aly.

A'ne

Ar#&r(#()

Ba'$ a(n

Br(##le /(nerna(l)'Kema

Fo%#

"#'&(n; )$(n

o(n# a(n

Le 'ram) or a(n)

%l#(le roo# 'anal)

❑ Po%nd(n &eada'&e) l($e &ead () exlod(n

❑ !eada'&e) aro%nd eye) or /ore&ead

❑ (ra(ne)

Lo)) o/ memory

Pan(' a##a'$)

Per(&eral ne%roa#&y

Poor 'on'en#ra#(on

>&a$y &and)

%)'le 'ram)

,e'$ a(n

O)#eoro)()a)&e)

o)a'ea

>#(//; a'&(n or a(n/%l m%)'le)

ee#& r(nd(n

en)e m%)'le)

Eea$ le); $nee) or an$le)

()# an# o#&er (llne))e) anyone (n yo%r /am(ly &a) &ad.



xamle; yo%r Dad &ad Can'er.

Add any add(#(onal (n/orma#(on yo% /eel may be &el/%l (n e+al%a#(n yo%r )(#%a#(on.

"n#a$e !erbal()# ,o#e)- Plea)e do no# r(#e (n #&() area.



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Herb Intake Template Start - Copy