Gaias Gift

Please complete the form to best of your ability. If you feel that you do not want to disclose certain
information that is your choice, but it can affect our work together.
All information is kept confidential and private. Please sign attached waiver and privacy statement.
Name ____________________________________________________
Address ___________________________________________________
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Phone (optional) - ______- ____________ (home)
______- ____________ (work)
Email (required) - ___________________________________________
Occupation - ___________________________________________________
Gender Male ____ Female____
Age- ______
Married___ Single___ Divorced___ Partnership____
How is the relationship____________________________________________________________________________________
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Children____ Number of Children____ Ages of Children_____
Are you currently breastfeeding or Pregnant?____________________
Are you trying to become pregnant?__________________
Reason for Visit____________________________________________________________________________________
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Primary Complaint-________________________________________________________
Where on body is complaint-________________________________________________________
Duration-_______________________________________________________

Complaint is often accompanied by (could be a food sources, stress,

etc)_______________________________________________________________________________
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History of Complaint____________________________________________________________________________________
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Past Medical HistoryChildhood illnesses, hospitalizations, trauma.
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Major Illness____________________________________________________________________________________
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Surgeries____________________________________________________________________________________
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Pregnancies____________________________________________________________________________________
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How was the Birth experience?
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Abortions, Miscarriages____________________________________________________________________________________
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Allergies____________________________________________________________________________________
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Accidents____________________________________________________________________________________
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Medications (all supplements, herbs, prescription and Over the Counter drugs)____________________________________________________________________________________
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Are any ailments such as Diabetes, High Blood Pressure, and Cancer in your family, if so please
explain what and their relation to you. Feel free to put down as much information as you wish, it is
all valuable to your health work up.
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Do you consume caffeine, if so how much?____________________________________________
Do you smoke? If so, how many cigarettes a day?
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How much Alcohol do you consume?___________________________________
Do you use recreational or habit sustaining drugs, heroin, marijuana, cocaine, etc?____
What are the drugs? __________________________________________________________

How much Red Meat do you consume a week?

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Fish, shellfish
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Fowl _______________________________________________________________________________
Are you Vegan or Vegetarian?____________

If female how is your menstrual cycle?

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How are your Energy Levels?
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Are you willing to keep a food diary?________
Daily Exercise, what and how much?
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If you had to rate your stress levels on a scale of 1-10 with ten being the highest how to you rate
your daily life?__________________________
How many hours of sleep do you get a day?_________
How would you describe your sleep?
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Circle Symptoms and add anything you feel is pertinent?

o
o
o
o
o
o
o
o
o

Nervous System
Stress
Worries
Headaches
Migraines
Dizziness, Fainting
Hearing
Vision
Pins and Needles

How is your sleep?

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Muscular Skeletal Systems

o
o
o
o
o
o
o

Joint Pain
Osteoarthritis
Rheumatoid Arthritis
Gout
Edema
Weakness
Broken bones

Accidents, especially automobile_______________________________________________

Good Balance
o
o
o
o
o
o
o
o
o
o

Endocrine System
Height and Weight
Body Weight Distribution
Adrenals
Thyroid
Sweating Tremors
Reproductive System
Cycle Regular, clots, and breast tenderness
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Breast Health________________________________________________________________
Menarche

Cramps (explain)
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o
o
o
o
o

PMS
Birth Control
Ovulation
Menopause
Prostate issues
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o
o
o

Continence
Infections
Yeast Infections

o
o
o
o

Venereal Disease
Digestive System
Stools, how are stools, mucus present, dry, hard, liquid,
color?___________________________________________________
How many a day?__________

o
o
o
o
o
o
o
o

Gas
Hemorrhoids
Cravings
Appetite_________________________________________________
Vomiting
Heart Burn
Bad Breathe
Bloating

Respiratory System
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

Cough
Coughing mucus/blood
Phlegm, what color____________________________________________________
Bronchitis
Pneumonia
Asthma
Painful Breathing
Allergies
Skin
Color
Temperature
Rashes
Acne
Dandruff
Rosacea
Anything else
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Urinary System
o
o
o
o
o
o

Frequency
Impotency
Difficulty stopping or starting flow
Kidney Stones
Blood in Urine
Irregular Flow

Urgency of Urination
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Are there any issues you wish to discuss?

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Do you have any health issues you would like to cover today?
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Emotional Issues____________________________________________________________________________________
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Health Concerns
Anything Else that you feel is essential to our work together, emotional complaints etc.
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Amount of TV/Computer time a day?
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Types of Cleaning Products Used, Detergents, etc..
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Waiver of Liability
I, understand I have the constitutional right to pursue various health practices and consult whom I wish to
achieve my goals for better health. I also understand that I am working with a consultant who makes no
claims of being a health practitioner; I do this on my own free will.
I understand no diagnosis, or prescription will be given. I understand that Jennifer Morgan is an
Herbalist and that she is not a medical doctor. I also understand that only a medical doctor can
diagnose and prescribe treatment.
The suggestions given are only suggestions and I must take responsibility for further educating and
making myself aware of my bodys heath issues and receiving proper medical care. I also understand that
this is not a medical appointment and only a Medical Doctor can provide that type of care.
________________________accept no responsibility for my actions upon leaving her office, financial or
otherwise for the outcome of herbal treatment recommended by the above mentioned consultant,
Herbalist. I also understand that Gaias Gift, Jennifer Morgan accept no responsibility for the effects of
said advice.
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Signature
Date