Bo-tanics — Pre-Appointment Questionnaire

1🌿

Personal Details

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Full Name *

Date of Birth

Age

Gender

Occupation

Relationship Status

Height

Weight

Eye Colour

Today's Date

Email Address *

Required — Bo will reply to this address

Phone Number

Currently pregnant or trying to conceive Currently breastfeeding

2⚡

Energy Goals & Presenting Concerns

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How would you describe your main energy concern? *

How long have you been experiencing low or disrupted energy?

Main energy symptoms — tick all that apply

What do you feel may be contributing? — tick all that apply

What are your health goals from this programme?

What makes your energy worse?

What makes your energy better?

Previous treatment for energy issues

3🩺

Medical History

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Current diagnosed conditions

Past illnesses, conditions & operations

Family medical history

Relevant blood test results (if known)

Allergies

Drug / medication allergies

Food or environmental allergies

4💊

Current Medications & Supplements

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Prescription medications

Over-the-counter medications (regular use)

Vitamins, minerals & supplements

Herbal medicines or tinctures (currently taking)

5💧

Hydration & Nutrition

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Hydration

Water intake per day

Main source of hydration

Urine colour (general)

Signs of dehydration you experience — tick all that apply

Dry mouth / lips Headaches in afternoon Mid-afternoon fatigue / brain fog Dry skin / eyes Muscle cramps Constipation Rarely feel thirsty

Bowel health

Bowel movements

Stool consistency (Bristol scale)

Any blood, mucus or unusual appearance?

Diet type

Meal patterns

Meals per day

Appetite

Overall diet quality

Blood sugar patterns — tick all that apply

Energy dips between meals Need to eat every 2–3 hours Irritable when hungry Strong sugar cravings Energy spike then crash after eating Fatigue / sleepiness after meals Skip meals often Poor appetite in morning

Stimulants & substances

Tea / coffee per day

Alcohol

Smoking

Recreational substances

Typical daily diet

Typical breakfast

Typical lunch

Typical dinner

Known food intolerances or sensitivities

Foods you avoid or dislike

Any additional dietary notes

6🌿

Stress, Mood & Lifestyle

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Your current stress level

On a scale of 1–10, how stressed do you feel right now?

5

Very little stressModerateExtremely stressed

Main sources of stress — tick all that apply

Work or career pressure Relationships or family Financial worries Caring for others My own health concerns A major life change or transition Bereavement or grief Feeling isolated or lonely

Movement & nature

How often do you exercise or move your body?

Time outdoors or in nature

How you are feeling right now — tick all that apply

Is there anything happening in your life right now — personally, professionally, or emotionally — that you feel may be affecting your health or energy?

7🌙

Sleep

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Average hours sleep per night

Sleep quality overall

How do you feel on waking?

Sleep issues — tick all that apply

Anything else about your sleep?

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Client Waiver & Informed Consent

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Acknowledgement of Practitioner Scope

I understand that Bo Lemm is not a licensed medical doctor and does not diagnose, treat, cure, or prescribe for medical conditions. Herbal and energy balancing services are intended to support overall wellness and are not a substitute for professional medical care.

Recommendation to Consult a Medical Professional

If I have, or suspect I may have, a serious medical condition, I am advised to consult a licensed doctor. Any recommendations are complementary and should not replace medical advice or treatment from licensed professionals.

Assumption of Responsibility

I am fully responsible for my own health and wellbeing and any decisions I make based on the services or recommendations provided. I take full responsibility for my individual responses to the herbal or energy balancing programme.

Release of Liability

I hereby release Bo Lemm @ Bo-tanics from any liability for adverse outcomes or reactions arising from my participation in the herbal and energy balancing programme. I understand that results may vary from person to person.

Informed Consent

I confirm that I have been provided with sufficient information about the services offered and have had the opportunity to ask questions. I enter this agreement voluntarily and understand its terms.

Confidentiality

Information provided on this form will be held in strict confidence by Bo-tanics Aroma-Herbary and used solely for the purpose of preparing and personalising my consultation and programme.

Client Signature

Full Name (print) *

Date

Signature — type your full name *

Questions? Contact Bo at herbs@bo-tanics.com · www.bo-tanics.com

Bo-tanics Herbal

Welcome — thank you for taking the time to complete this form.