Online Herbal Consultation Form

Online Herbal Consultation Form

If for some reason, you are unable to attend  our Clinic then the Online Herbal Consultation Form is designed for your convenience. By filling in this form you are providing the  Herbalist with up to date accurate information about your current symptoms, gerneral health, diet, current medications, any current or past medical conditions, lifestyle,etc. The more detailed & accurate the information is, the better the Herbalist can assess your condition and make subsequent recommendations. This enables the herbalist to get a complete holistic view of your present situation and to assess how any of these things may be impacting on your current state of health. Because herbal medicine takes a holistic approach, it allows the herbalist to know more about you as an individual. In developing a treatment plan, it allows the herbalist to choose herbs and natural healing protocols that treat the person as a whole and not just the presenting symptoms. Learn more about Herbal Medicine

This type of Online Consulation Form is suitable for many minor condition, but if it deemed by the herbalist that the condition is of a more serious nature then a direct 1-2-1 consultation maybe required.

Individual Herbal Remedies

The herbs chosen & herbal remedies developed for each person are specific and individualised for each person; we are all uniquely different so what works for one person may not work for another. Herbalists work on the premise that we have an innate ability to heal ourselves, that the body is a self-healing organism, and that herbal medicine and diet should be used to support the body’s very own capable defensive and restorative mechanisms, rather than by trying to replace them.

To recieve Herbal Remedies prescribed by the Herbalist you need to complete this Consultation Form first. This is a requirement under Irish Law.

The  Herbalist is a fully qualified, certified and experienced Medical Herbalist , so your information will be assess by a Herbalist with extensive knowledge and experience. Learn more about The Herbalist

If you have a current health condition, it is recommeded that you undertake a treatment plan for a minimumn of 3 months in order to have effective lasting results with monthly Follow-up’s during this period to assess your progress.

Once you’ve completed the form, submit the form to us by clicking on the ‘submit’ button at the end of the form. Our medical herbalist will assess your case and then make contact with you (either by phone or skype) to clarify any uncertainties and to ask you some more relevant questions which will help in developing a treatment plan. A  full detailed treatment plan including dietary changes, lifestyle changes, natural healing protocols, guidence on any herbal remedies will be emailed to you. There will be ongoing access by email for any queries that you may have.

Payment for the Consultation  and any Herbal Remedies is required in advanced by credit card before been dispached. €5 Post & Packaging applied to all deliveries of Herbal Remedies nationwide. See Terms & Conditions      For Consultations & Prices Please Click HERE

ALL INFORMATION SUBMITTED IS TREATED AS A MEDICAL RECORD AND NOT AVAILABLE TO ANY THIRD PARTY FOR ANY REASON AT ANY TIME.


In filling out the form, you are not limited to the space indicated by the boxes. You can continue typing and we will receive all the information you provide.

Full Name:                     

Your Date Of Birth:     

Mailing Address:         

Phone Number:           

Email Address:            

Skype ID:            

Gender:                         

Do you suffer from any ongoing diagnosed medical conditions?
If so please specify

Yes – please name condition:
No


Are you taking any medications (please include Contraceptive Pill, Herbal Medications and or Vitamin supplements)?

No – please continue to next question.
Yes – If so please list, than continue to next question

Name / Brand of Medication        Dosage                             How long have you been taking this medication
                   

                   

                   

                   

                   

                   


 

Are you Pregnant/Breastfeeding?

No – please continue to next question.
Yes – If so, sorry we can not supply you with any of our Herbal Remedies  at this stage. Please consult your nearest Herbalist and enjoy your pregnancy. (Please note we do not prescribe herbal medicines to pregnant women we have not personally seen as 1-2-1 patients in the clinic.)


Do you suffer from any Allergies?

No
Yes – please give details of allergy:

Name / Brand of Medication        Dosage                             How long have you been taking this medication
                                    


Tell us a little more about your self….

1. Describe Your Sleeping Pattern?                

2. Any Family History Of Illness on your mother’s or father’s side. Give details? 

3. Describe Your Bowel Situation, normal/ constipated? How often a day? 

4.  Do You Smoke/Drink Alcohol, if so how much per week? 
5.  Any Past Illness/Surgeries/Injuries when you were younger? 

6.  How Would You Describe Your Stress levels,at home & work?  
7. Any Past Medications? Give details 

8. Do You Get Regular Exercise, if so give more details? 
9. Is menstrual cycle normal? Contraceptive Pill? O IUD? Give details.  
10.  Any other information you may feel relevant? 


Diet: 

 Please give a detailed answer, you are not limited to the space indicated by the boxes. You can continue typing and we will receive all the information you provide.

  1. Describe your typical breakfast? 

2. Describe your typical lunch?  

3. Describe your typical dinner? 

4. Do you eat much processed foods?  
5. Do you eat much white products, like pasta, bread & rice? 

6. Do you eat much snacks? Crisps, Fizzy drinks, biscuits, etc
7. Do you add salt to your food?  

8. Do you drink black tea/coffee, if so how much per day? 

9. How much water do you drink daily? 

10. Do you use Green Juices? 


What are your current symptoms?

(eg: Headache, back pain, etc.) please give a detailed answer, you are not limited to the space indicated by the boxes. You can continue typing and we will receive all the information you provide.

Symptom(s)                                Period of time symptom has been present.
              

              

              

              

              

              

              

              


Please type any extra information, or questions you may have in the text box below.

By submitting your information, you acknowledge and confirm that all the information provide  by you is true and correct to the best of your knowledge.

ALL INFORMATION SUBMITTED IS TREATED AS A MEDICAL RECORD AND NOT AVAILABLE TO ANYONE FOR ANY REASON AT ANY TIME.

To make an appointment  to visit the clinic for a 1-2-1 appointment with the Herbalist
phone: 085-215 7479

** Some conditions maybe deemed by the herbalist that it might be more appropriate to attend the clinic directly for treatment.

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