Bo-tanics Herbal: Consultation Intake

Thank you for taking the time to complete this form before we meet. There are no right or wrong answers, and nothing here is a test. The fuller and more honest your answers, the better I can understand the whole picture and prepare something truly personal for you.

It takes around fifteen to twenty minutes. Everything you write is held in strict confidence and used only to prepare your consultation. Please answer what you can, and leave anything that does not apply.

This form is not for medical emergencies. If you have symptoms that are severe, sudden, or getting rapidly worse, please contact your doctor or emergency services. Herbal support sits alongside medical care, never in place of it.

About you

The practical details so I can prepare your notes and reach you.

Full name *

Date of birth

Age

Gender

Occupation

Relationship status (optional)

Height

Weight

Email address *

Phone number (optional)

How did you find me? (optional)

Why you are here

In your own words. This is the heart of it, so take your time.

What is the main thing you would like help with? *

How long has this been going on?

Anything acute or recent (short-term, flared up lately)

Anything long-term or recurring (ongoing, or that keeps coming back)

What makes it worse?

What makes it better?

What have you already tried?

Your goals

Where you would like this work to take you.

What would restored health look and feel like for you?

How ready do you feel to make changes to your diet and lifestyle?

Ready for a full commitment Willing, with gentle steps Prefer mostly herbs for now Not sure yet

Any budget or practical constraints I should know about? (optional)

Medical history and safety

This helps me work safely alongside any care you already have.

Currently diagnosed conditions

Significant past illnesses, operations, accidents or hospitalisations

Family medical history

Recent test results, if you have them

Drug or medication allergies

Food or environmental allergies

Recent or repeated antibiotic use in the last year

Medications and supplements

Everything you take regularly, so I can check for interactions.

Prescription medications

Over-the-counter medicines you use regularly

Vitamins, minerals and supplements

Herbal remedies, teas or tinctures you currently take

Reproductive and hormonal health

Please begin with the safety question, then share what is relevant to you.

Are you pregnant, breastfeeding, or trying to conceive?

No Pregnant Breastfeeding Trying to conceive

Where are you in your cycle or menopause journey?

Cycle length / regularity

Flow

Period pain

HRT or hormonal contraception

Any gynaecological surgery or history

Anything else about your hormonal or reproductive health (optional)

Body systems review

Please open each system and tick anything you experience regularly now, or have a tendency towards even if it is quiet today. This is what lets me support the whole body, not just one symptom.

Diet and hydration

An honest sense of how you eat and drink day to day.

Water per day

Tea / coffee per day

Alcohol

Meals per day

Appetite

Smoking

Overall, how would you describe your diet?

Typical breakfast

Typical lunch

Typical dinner

Do any of these patterns sound like you?

Food intolerances or sensitivities

Foods you avoid or dislike

Any dietary history worth mentioning (optional)

Lifestyle and stress

How your days are shaped, and how much pressure you are under.

On a scale of one to ten, how stressed do you feel these days?

CalmOverwhelmed

How often do you move your body?

Time outdoors or in nature

What does a typical working day look like?

Recreational substances (optional, confidential)

Sleep

Rest is where a great deal of healing happens.

Average hours per night

Sleep quality

How do you feel on waking?

Any of these? (tick any)

Anything else about your sleep? (optional)

Anything else

The last word is yours.

Anything at all you would like me to know that we have not covered?

What matters most to you about this work?

Waiver and informed consent

Please read and agree before submitting.

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 work is intended to support overall wellbeing and is not a substitute for professional medical care.

If I have, or suspect I may have, a serious medical condition, I understand I should consult a licensed doctor. Any recommendations given are complementary and should sit alongside, not replace, medical advice or treatment.

I take full responsibility for my own health and wellbeing, and for any decisions I make based on the recommendations provided, including my individual responses to a herbal programme.

I release Bo Lemm at Bo-tanics from liability for adverse outcomes arising from my participation, and I understand that results vary from person to person.

The information on this form is held in strict confidence by Bo-tanics and used solely to prepare and personalise my consultation and programme.

Full name (print) *

Date

Signature (type your full name) *

Thank you, your form has been received.

I will read it carefully before we meet, and prepare something shaped around the whole of you. If anything urgent comes up in the meantime, please contact your doctor.

With warmth,
Bo

Bo-tanics Aroma-Herbary · herbs@bo-tanics.com · www.bo-tanics.com
Held in strict confidence. Herbal support sits alongside medical care, never in place of it.

Herbal Consultation Intake