CLIENT INTAKE FORM
Please fill out all forms so that master herbalist can do a superior assessment . Every item is important in order to create a comprehensive assessment report for you. It will determine the correct herb formula, diet, and lifestyle recommendations
Payment is due at time of service unless special arrangements are made in advance. Signature below authorizes and consents to care by Longevity Mountain, Health Clinic & staff. I will call the staff, if there is any problem and come in for appointment(s) for adjustment in formulation, if needed. I understand that diet, weather, lifestyle, thought, emotions and physicality all have bearing on outcome and may determine the term of correction. With severe chronic conditions, it took time to arrive at imbalance and will need your patience to naturally resolve without causing further adverse effects.
CLIENT INTAKE FORM
Please click on all conditions that are relevant to you in Parts A-H, etc. and fill in text areas to clarify the condition, as needed.
Please provide what a typical day would like. Record all the foods you eat and drink. Be sure to include the approximate amount of each food. When you have completed this booklet, return it to your healthcare practitioner for evaluation. Your diet may be the key to better health.
CONSTITUTION ASSESSMENT SECTION
Scoring: Give yourself 1 point for mild symptoms (1-2 events per month), 2 points for moderate symptoms (3-6 events per month), 3 points for a severe condition (7 events+ per month). If a condition doesn’t apply then leave the item blank. Men and women fill out both Yin and Yang sections. For unclear items, consult your Traditional Chinese Medicine practitioner.
What Happens Next!
Your practitioner will assess the info for you and dive deep to find the underlying cause of all your conditions. Determination will be based on patterns the herbalist(s) perceives based on Chinese medicine theory, other global medical systems, experience, advanced nutrition and your experience with the conditions (very valuable). Once findings are provided to you in a report then the herbalist and you will have a vital discussion, with your thoughts and his, to arrive at a sound, practical strategy that works for you, not him.
The senior master herbalist will recommend Chinese medicine formula, a food therapy regimen, additional modalities, as needed, etc. There will be conversation, as to whether, an additional appointment is needed and future communication.
Your success is dependent on the both of us working together. Any rare reactions need to be shared immediately because it is critical to your well-being and future. It is usually due to diet rather than formula but may be hard to discern at the time. However, if it is due to formula selection then you will see the herbalist quick to remedy the situation. Bottom-line, the herbalist cares about you very much and thinks about all his clients’ well-being.
Based on the assessment and your input, I will send you:
- Food Therapy Report
- Instructions on each formula including dose and duration
- Recovery expectations
- Additional reports as needed
The report is customized to support your general constitution requirements. For complaints such as cancer, diabetes, heart disease, obesity, brain function and hormonal disorders, please consult, in detail, with your practitioner. He really wants to know, to serve you better.
Mark Hammer, CMHIII
Senior Master Herbalist
Longevity Mountain Herbs