GivingTree Farm Herb Company

Constitutional Intake Form

Lawrence Birch  Certified Clinical Herbalist  CCH

760 Sw Madison Avenue

Suite #11 A

Corvallis, OR 97333


Directions For Filling Out The Form:

Please fill out the form as completely as possible, which should take about 15 - 30 minutes. If you need help answering questions, please ask me. If you wish to elaborate on a question or condition, you may include additional information. You may drop off the form at my office or mailbox in the the Central Park South building (across from the Corvallis Art Center by Central Park) at 760 Sw Madison Avenue/Suite 11 A/ Corvallis, OR 97333. Or you may send your completed form to me via “snail” mail, or scan it and email it to me, or take clear, focused pictures of each page and text it to me. Lots of options! I will review it right away and contact you to set up your appointment.

During your appointment with me, we will discuss any herbs and other things that might be appropriate for you, and I may suggest herbs to tone your particular constitution. The information I share with you should be taken as educational, not diagnostic nor prescriptive. The personal health information you share with me is completely confidential, however, I may feel the need to discuss your issues with a colleague or your current health care practitioner. Please inform me if you do not consent to this arrangement.

There is no charge to fill out the form and for me to review it. My consultations in person, over the phone, via video conferencing or email, generally run from one to two hours and my fee is on a sliding scale, $55 to $155 per hour for your initial consultation, based on your ability to pay. Your initial fee includes a 15 minute follow up within two weeks. Any additional follow-ups by phone or email are $1/minute, 30 minute minimum. In person or video follow ups are $60 - $90 for 30 minutes. The cost of an herbal preparation, should you decide to get it from me, will cost around $15 to $35.  Nobody will be refused a consultation for lack of funds.

GivingTree Farm Herb Company     Constitutional Intake Form

Name:________________________________     Phone:_________________  Today’s Date:____/____/____

Your Birth Date:____/____/____   Mailing Address:  ____________________________________________

Email: ____________________________________       ____________________________________________

DIRECTIONS: For every statement on this and the following pages, simply check or place an "X" beside all the descriptions that apply, except where otherwise indicated.


___ Sometimes nausea in mornings

___Sometimes nausea in evenings

___ Sometimes excess salivation

___Mouth frequently too dry

___Duodenal ulcer

___ Stomach ulcer

___Sometimes foul burps

___Butterflies in stomach

___Seldom eat breakfast

___Often don’t finish meals

___Often eat to calm down

___Receding gums

___Frequent use of alcohol

___Frequent poor appetite

___ Strong, demanding hunger

___Bitter taste in morning

___”Dragon breath” in mornings

___Acid indigestion at night

___Frequent mouth or cold sores

___Sometimes difficulty in swallowing

___Indigestion after eating


___ Stools loose with gas

___Constipation with gas

___Frequent constipation

___ Digestion unusually rapid

___ Loose stools when tired/stressed

___Light colored, hard stools

___ Dark, soft stools

___ Quick defecation after eating

___Intestines often feel bloated

___Constipation with hemorrhoids

___Constipation w/ painful defecation

___Constipation w/ hard, marbly stools

___Constipation w/ fully formed stools

___Constipation alternating with diarrhea

___Frequent need for laxatives

___Tongue often coated


___Dry, even scaly skin

___ Moist, sometimes oily skin

___Hives from food or drugs

___Hay fever or asthma

___Crave proteins, fats

___Crave fruit or sweets

___Frequent trouble digesting fats

___Acne on face AND buttocks

___Seems to have low blood sugar

___Had hepatitis in past

___Frequent use of alcohol

___Work with solvents

___Psoriasis, eczema, dermatitis

___Frequent minor illnesses

___ Fever w/ sweat when sick

___Don’t sweat when sick


___ Standing too quickly makes pulse roar in ears

___Standing too quickly causes dizziness, faintness

___Wakes up at night to urinate

___Frequent flushing or blushing

___Water retention with change of weather

___ Moderate high blood pressure, crave fats

___Moderate low blood pressure, crave sweets

___Frequent thirst

___Craving for salt

___Urine always light colored

___Urine usually darker

___Sometimes difficulty in swallowing

___Indigestion after eating


___Frequent urination, small amounts

___ Infrequent urination, copious

___Sometimes dribbles urine afterwards

___Frequent bladder infections

___Demanding and sudden need to urinate

___Mucus in urine

___Benign prostatic hypertrophy (males)

___Dull ache after urination


___ Sweat freely with strong scent

___ Oily skin, facial acne

___Dry skin, cold hands and feet


___Cycle more than 28 days

___ Cycle less than 28 days

___ Water retention before menses:  hips, breasts

___Water retention before menses:  feet, hands

___ Craves fats, proteins before menses, usually

___Craves sweets before menses, usually

___ Sides of breasts tender before menses

___Miss some periods

___Menses slow starting with cramps

___ Palpitations before menses

___Menstruation lengthy, frequent cramps

___ Menstruation short, defined, few cramps

___Frequent Class II Pap smears

___History of PID, cervicitis

___Miscarriages, problem pregnancy

___ Period early with altitude change

___Period late with altitude change

___Tried, but couldn’t handle birth control pills

___Frequent candida-type infections


___Frequent cannabis user

___Pain or ache after orgasm

___Benign prostatic hypertrophy

___Difficulty maintaining erection even if you

feel in the mood


___Shortness of breath when standing/walking

___Tobacco smoker

___ Easy coughing of mucus

___Difficulty swallowing mucus

___Rapid shallow breather

___Sometimes wake up choking/gasping for


___Yawn frequently

___ Sometimes hyperventilates

___Frequent chest colds


___ Strong, slow pulse

___Fast, light pulse

___ Frequent physical activity

___ Warm bodied

___Cold bodied

___Sometimes dizzy or faint

___ Hands warm, sweaty

___Hands cold, clammy or dry

___ Palpitations either as an adolescent

or before menses

___Hypertension, responds to diuretics

___Hypertension, not responding to diuretics


___ Recuperate quickly if ill

___Recuperate slowly if ill

___ Injuries heal quickly

___Injuries heal slowly

___Eczema, dermatitis

___Asthma or hay fever

___Arthritis or rheumatism

___ Digest fats easily

___Digest fats poorly


___ Skin eruptions superficial, come to a head

___Skin eruptions deep, don’t come to a head

___Skin on trunk is dry

___ Oily scalp or hair

___Dry scalp or hair

___Cracks, fissures on heels, feet; slow healing


___Sores, cracks on mouth, anus, and/or vagina

___Lips often dry, chapped

___Food often causes pain passing through


___Get sore throat easily


Only mark conditions that are frequent. For a mild

condition write “1. ” Dominant conditions write “2.”

___Use aluminum cooking vessels

___Awaken, can’t go back to sleep

___Bad dreams

___Blurred vision

___Brown spots, bronzing of skin

___Bruises easily

___Can’t gain weight

___Can’t lose weight

___Can’t get started without coffee

___Chemical or spray poisoning

___Chronic fatigue, depression

___Cry easily without seeming cause

___Depressed for long periods of time


___Eat often or else feel faint/nervous

___Eyes often red, inflamed

___Face, eyes get puffy

___Facial twitches

___Gum problems

___Tooth problems


___Headaches in mornings, wearing off

___Heart palpitations when hungry

___Heart palpitations after eating

___Highly emotional

___Highly controlled

___Impaired hearing

___Increase in weight (recent)

___Lack of sensation somewhere in the body

___Like depressants

___Like stimulants

___Lower back pain

___Frequent muscle cramps

___Nails split, brittle

___Nails weak, ridges

___Nosebleeds frequently

___Pollution heavy in work or home environment

___Ringing in ears

___Pulse speeds up after meals

___Sensitive to cold weather

___Sensitive to hot weather

___Sensitive to high humidity

___Sensitive to low humidity

___Sexual desire decreased

___Sexual desire increased

___Stuffy nose during the day

___Stuffy nose in evening, night

___Tendency, seemingly, to anemia

___Tremors in hands or neck

___Varicose veins

___Weight gain in upper arms/shoulders/back of neck


1) Are you currently under the care of a physician or other health care provider?  ___ Yes ___ No

  Name of your provider:_______________________________________________

2) Have you been diagnosed with a chronic condition?  If yes, please describe what it is:

______________ _____________________________________________________________

3) Have you been seriously ill or injured within the past 12 months? If yes, what happened:

____________ _____________________________________________________________

4) Have you been hospitalized within the past 12 months? If yes, for what reason(s):


5) Are you taking any prescription medications or receiving any kind of treatment? If yes please describe:  _____________________________________________________________


6) Do you take any vitamin, mineral or other supplements? If so, what kind and how often?



7) Please describe what you usually eat: __________________________________________________


8) Are you active or do you exercise regularly or participate in a sport? If so, what kind and how often?


9) How has the past year been for you mentally, emotionally, and spiritually?



10) How would you describe your mental and emotional health during the last 4 - 12 months?



11) Is there anything else you wish me to know that may be relevant to your health and this consultation?


Health History


____ ____ Are you pregnant/trying to get pregnant?

____ ____ Have you ever had any broken bones?

____ ____ Do you have a history of abuse?

____ ____ Have you ever had back problems?

____ ____ Do you wear contact lenses or glasses?

Have you (SELF) or a family member (FAM) ever been diagnosed with any of the following?  Family

members include grandparents, mother, father, and siblings.  Write “X” in column(s) where appropriate.


____       _____   Allergies

____       _____   Cancer

____       _____   Diabetes

____       _____   Elevated cholesterol

____       _____   Heart disease

____       _____   Hepatitis

____       _____   High blood pressure

____       _____   HIV

____       _____   Migraines

____       _____   Multiple Sclerosis

____       _____   Osteoporosis

____       _____   Parkinson’s

____       _____   Seizures

____       _____   Sexually transmitted infection

____       _____   Stroke

____       _____   Thyroid disease

____       _____   Other:  __________________

By signing this form I give my consent and authorize Lawrence Birch CCH to review the information in his possession for the purposes of completing my "constitutional review." I agree not to take any legal action against Lawrence Birch CCH, GivingTree Farm Herb Company or any of its agents or employees for any reason whatsoever. I also give my consent for Lawrence Birch CCH to confidentially discuss my information with another health care practitioner if he deems it necessary. Furthermore, I authorize Lawrence Birch CCH to contact my own health care practitioner(s) if necessary. I further understand that any information shared with me is just that, information not medical or other advice. Healing is ultimately my responsibility.

Print Name: _______________________________________________________________________  Date: _________________________

Signature: _______________________________________ Emergency contact name & phone #: ________________________________