Health History Intake Form for Flower Essence Consultations

Thank you for purchasing a Flower Essence Consultation!

Consultation can be done via SKYPE call or in-person at our center.

NOTE: Before you schedule a SKYPE call with us, you must first fill out the Health History Intake Form for your animal.

Health History Intake Form:

Your Order #*
Your order number can be found on the email receipt that was sent to you by [email protected] (not PayPal's invoice number).

It looks like this:
Your Name*
First Last
Your Email*
Download the Health History Intake or Use the Online Form*
You can either download the Health History form in Word/PDF format and then upload your completed intake to this form, or you can utilize the online form. Please choose from the following:
- Download the Health History Intake
- Utilize the Online Form

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Online Health History Intake Form
Date of Evaluation*
MM slash DD slash YYYY
Caregiver's Information
Client's Name (Animal)*
First Last
Caregiver's Name (Owner)*
First Last
Address
If you do not have the full address, please simply list the City and State.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Animal's Information
Age:
Sex:
Species:
Breed:
Neutered/Spayed:
Gelded/Stud:

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Health Information
Reason for Seeking Flower Essence Consultation:
Current Health Status:
Current Issues (Date started/known cause/acute/chronic. Use scale 1-10 for rating each issue)
Past Health Issues:
Vaccination History and Reactions:
Known Allergies or Medical Condition/s:
Diet: (include foods, supplements, herbs, homeopathy, medications and any changes in feed, times fed and behavior surrounding feed time/location etc.)
Digestion/Appetite (increase/decrease):
Skin and Coat: (include quality, texture, loss of hair, dry or oily skin, hot spots, wounds etc.)
Respiratory: (include allergies, breathing issues, infections, exposure to pathogens etc.)
Cardiovascular:
Muscle/Ligament/Tendon: (include texture, injuries, recovery turnaround, spasms/acute/chronic)
Bone/Joints/Disc/Spinal: (include injuries, degeneration, arthritis acute/chronic)
Sleep issues: (include imbalances, snoring, disruptive, wake time etc.)
Senses: Sight/Eyes, Sound/Ears, Taste/Tongue, Smell/Nose, Feel/Emotional Barometer, Speak/Vocal and Non-Vocal Expressions
Emotional: (balanced/imbalanced, past traumas/abuse issues, personality type/changes in)
List any surgery or medical procedures, serious health issues/concerns or if the animal is pregnant. Also list any holistic therapies currently used and applied in the past i.e.: acupuncture, aromatherapy, massage therapy, chiropractic, Reiki etc.
Are you currently using essential oils or botanicals, and if so, please list which and for what:
Additional Notes:

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Disclaimer Acknowledgment:
The information shared during the consultation evaluation is for personal education awareness only, it is not meant to diagnose or treat any serious health problems/conditions. I will agree to keep the practitioner updated on any new health issues and do not hold the practitioner responsible or liable for any health conditions/concerns that were not disclosed. I will use Flower Essences in a safe manner, for topical and inhalation use only. I am aware that all flower essences and products should be kept out of reach of children and animals.
I agree to the above disclaimer:*
- Yes
Date
MM slash DD slash YYYY

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You will receive email confirmation with the form fields you submitted.
Email
This field is for validation purposes and should be left unchanged.

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Online Health History Intake Form