Client Worksheet
 

Natural Herbal Therapy

Lucinda Robinson, Herbalist

815 A Wynnshire Drive

Hickory, NC 28601

1-828-358-0609

 

 

In order to help me help you, please print out this page and supply the information on the front of this page and the added sheet, and return to the address above. 
 

Name:_____________________________________________________

 

Age:______________________________________________________

 

Address:___________________________________________________

 

City, State, Zip:___________________________________________

 

E-mail:__________________________________________________

 

Fax:____________________________________________________

 

Phone:__________________________________________________

 

 

1.    List all the prescription drugs you are presently taking and the reason you are taking them.

2.    List all the over-the-counter drugs you use on a regular basis and the reason you use them.

3.    List all the nutritional supplements you use and the reason you use them.

 

 

4.    Sit someplace very quiet with a pencil and paper (without TV, radio, music, etc.). Mentally go over yourself head to feet, writing down anything you notice about your body that would tell you you do not have perfect health. This would include anything you have noticed in the last month. This should include skin conditions, lumps, soreness, pain, irregular bowel habits, or anything that is irregular.

5.    Please state a medical doctor’s diagnosis of any condition you have.

 

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