Name * First Name Last Name Email * Phone (###) ### #### DOB * MM DD YYYY Diagnosis * Have you been diagnosed? Yes No Type Please indicate the type of autoimmune disorder you've been diagnosed with. RA SLE IBD Hashimoto's Psoriasis MS Type 1 Diabetes Lupus Other None Symptoms: Fever/Body Temp * Higher Body Temperature Feeling cold when others feel hot Feeling hot when others feel cold Low body temperature Neither Symptoms: Hair * Hair Loss (round bald patches on scalp) Hair Loss (loss of facial and scalp hair) Male patterned baldness Excess hair growth (face, neck, chest, abdomen, thighs in women) Loss of hair in outer eyebrow Hair is rough, coarse, dry, breaking, brittle Neither Symptoms: Skin Hyperpigmentation Painful skin rashes Fragile, thin skin Skin that bruises easily Acne Skin rashes on the nose and cheeks Sun sensitivity Skin thickening Skin ulcers on the fingers Neither Symptoms: Eyes * Dry Blurred Discomfort/pain Jerking or rapid involuntary movement Inflammation of the nerves Unclear/Double vision Neither Symptoms: Fatigue/Sleep * Chronic Fatigue Insomnia Exhaustion after minimal effort Neither Symptoms: Muscles, Joints, Tendons * Pain and tenderness throughout the body Muscle weakness Joint stiffness Bone, joint and muscle aches, inflammation and pain Backaches, unexplained fractures of ribs Deformed joints Carpal-tunnel syndrome, tendinitis Neither Symptoms: Hands and Feet * Extreme sensitivity to cold Chronic swelling Neither Symptoms: Weight Changes * Weight loss Weight gain Weight gain in upper body or abdomen Puffy face Increased fat around the neck Thinning arms and legs Neither Symptoms: Digestion * Nausea, vomiting, or diarrhea Recurring abdominal bloating or pain Pale, foul smelling stool Gas Increased urination Constipation Neither Symptoms: Pulse/Blood Pressure * Low BP High BP Slow pulse Fast pulse Normal Symptoms: Mood/Thinking * Irritability,anxiety, and depression Brain fog, difficulty concentrating, forgetfulness Neither Symptoms: Balance, Coordination, Neurological * Lack of coordination or unsteady gait Dizziness, vertigo Numbness, weakness, tingling or paralysis in one or more limbs Tremor Neither Symptoms: Grub * Cravings of salty food Increased thirst Loss of appetite Normal Symptoms: Reproductive * Irregular or absent menstrual periods Decreased fertility in men Reduced sex drive Recurrent miscarriage Other None Symptoms: Breathing * Increased snoring Shortness of breath/tightness of chest Neither Symptoms: Blood * Sudden anemia High cholesterol levels Neither Symptoms: Sugar changes * Hypoglycemia/ low blood sugar High blood sugar Normal Concerns * Please explain any additional concerns or diagnosis. Include your current healthcare routine. Plan My condition is under control. Strongly Disagree Disagree Neutral Agree Strongly Agree I think natural & holistic care is a better option for me. Strongly Disagree Disagree Neutral Agree Strongly Agree Next Steps * What are you looking to gain? Info & Tips Treatment Recommendations See the Herbalist Start a Standard Wellness Plan Customize my Wellness Plan Alternative Insurance We don't accept insurance but have options so that you could get the plan you need. FSA HSA Thank you! We are excited to assist you on your Journey to Wellness. Please sign up to receive tips and specials for services that will help you improve your overall health and well-being.
