Intake Submission Template
General Client Information
Age:Weight:Height:Sex/Gender:
Constitutional indicators:
Energetics/Pulse:
Energetics/Tongue
Overall vitality:
Current overall health rating
Primary complaint/ reason for visit: OPQRST
Current rating of primary complaint:
Secondary complaint: OPQ RST
Current rating of secondary complaint:
***Please list and include OPQRST and rating for any additional complaint
Health History
Last physical exam:
Last gynecological exam:
Physician’s diagnosis:
Lab findings:
Medications, current or recent:
Supplements/ herbal remedies, current or recent:
(chart all medications and submit as a separate document)
Medical history (general state of health, childhood illnesses, adult illnesses, psychiatric care, car accidents, injuries, traumas, surgeries, hospitalizations), list as a time line:
Family medical history:
Social/emotional history (living situation, abuse or emotional trauma, divorce, loss, sexual history, financial situation, etc.):
Family/life relationships:
Spiritual beliefs:
Present outlook on life:
What gives the client joy:
What give the client a sense of significance/Calling
Hobbies:
Diet and Lifestyle
Stress:
Sleep:
Exercise:
Diet:
- breakfast:
- lunch:
- dinner:
- snacks:
- oils:
- water consumption:
- soda/energy drink consumption:
- caffeine consumption:
- sweets:
- food cravings:
- what does the client consume when they are not eating what is listed above:
Recreational drug use:
Cannabis use:
Tobacco use:
Alcohol consumption:
Caffeine consumption:
Nutrient deficiencies:
System Review
***Include all Red Flags: identify all red flags by highlighting in red!
General:
Skin:
Nails:
Hair:
Eyes:
Ears:
Mouth/throat/tongue:
Brain:
Upper respiratory:
Lower respiratory:
Cardiovascular:
Upper GI:
Lower GI:
Hepatic:
Urinary:
Reproductive:
Musculoskeletal:
Neurological:
Endocrine:
Affective:
Case Analysis
Herbalist summary:
Patterns:
Therapeutic strategy:
Flower essence indications:
Identified red flags: please highlight in red:
Additional relevant information/impressions:
***Submit case research as a separate document using the research template
Protocol and Education
***Include acute, short-term and long-term suggestions and a sequential plan of action in this section. The more information faculty is given, the better the quality of our feedback will be.
Initial protocol:
Education:
Lifestyle recommendations:
Dietary changes:
Details of how you are addressing identified red flags, please highlight in red:
Referrals given to client:
Flower essences:
Supplements, include dose and frequency:
Herbal simples or formulas:
***For each herbal formula/simple dispensed:
Identify form: tincture, tea, powder, oil, salve, etc.
Identify each herb by Latin binomial
Include the quantity of each herb in every formula
Include total quantity of formula dispensed
Include dosage quantity and frequency
Include quantity of each low dose botanical per dose
Include length of time the client is expected to take the formula
Include your rationale for the formula or simple
*** Was the herbal protocol dispensed or are you waiting for feedback?
***Which faculty member approved your formula(s)/simple(s)?
Next Steps
- Identify your long-term plan for the case
- Include what is going to be addressed on the next follow-up visit
- Include the list of goals, both yours and the client's
- Include your strategy, how should the case progress?
Clinical insights:
Personal learning issues:
Follow up visit scheduled? When?
***Specific case-related questions: Please list any specific questions for faculty here and highlight in yellow.