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Submit your question by April 15th, 2024.

I will answer all questions in an audio Q&A that I will email to you on April 19th, 2024.

If you submit a question after April 15th, 2024, I will do my best to answer it in a timely manner but I can make no guarantees.

Herbal Formula Intake Form

Name

First Name

Last Name

Age & Sex

Height & Weight

This is relevant for dosing. Your best guess is sufficient.

Blood Pressure & Heart Rate

It's ok if you don't know this, but it's helpful if you do.

What triggers your allergies?

Please describe your current (within the past 2 years) allergy symptoms:

How often do you experience these symptoms?

When did you first experience allergies?

Other Body Systems

Your formula will be specific to allergies, but I'd like to get a sense of your overall health picture. If you have any health issues in the following areas, briefly describe them. If you have no issues with that area, leave it blank.

Digestion

Please describe your bowel movements: frequency, texture, color.

Musculoskeletal:

Nervous System, Brain, Mental Health:

Reproductive Health:

Ears, Eyes, Nose, Throat, Skin:

Kidneys & Urinary Tract:

Respiratory:

Liver:

Please describe your sleep. How well do you sleep? Do you wake feeling rested?

Do you run hot or cold?

Will you take an alcohol-based tincture?

Yes

Please list any medications, including the dose and when you take them:

Please list any supplements and herbs you take daily:

Anything else you'd like me to know?

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Herbal Formula Intake Form

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