First Name *

Last Name *

Email *

Age *

Primary Health Goal for this formulation *

List one thing you want to focus on with these herbs.

Choose your preferred formula type *

Tea Blend
Tincture

Tea blends are loose leaf and will need to be brewed daily for medicinal results. Tincture are concentrated, portable and more convenient, and are in an alcohol based but the daily amount is very low.

Please list all symptoms & conditions *

List all current symptoms regardless of obvious relation to your main concern.

Please list any major medical history *

Particularly anything related to the liver, kidneys, cardiovascular system or blood blotting disorders.

Have you had surgery in the past 1-2 years? *

Yes (please list in above section)
No

Tea blends are loose leaf and will need to be brewed daily for medicinal results. Tincture are concentrated, portable and more convenient, and are in an alcohol based but the daily amount is very low.

Please list any allergies *

Are you on any medications? *

Yes
No

Tea blends are loose leaf and will need to be brewed daily for medicinal results. Tincture are concentrated, portable and more convenient, and are in an alcohol based but the daily amount is very low.

If YES, please list medications here

List any herbs/supplements you're taking *

Are you pregnant or breastfeeding? *

Yes Pregnant
Yes Breastfeeding
No

Tea blends are loose leaf and will need to be brewed daily for medicinal results. Tincture are concentrated, portable and more convenient, and are in an alcohol based but the daily amount is very low.

What is the general level of stress in your life? *

1 10

1=low, 10=Unbearable

What's the quality of your sleep? *

1 10

1=insomnia, 10= Great, 8+ hrs of restful sleep

How much movement do you have in your life? *

1 10

1= Sedentary, 10= 1hr+ daily exercise

How good is your nutrition? *

1 10

1=feel undernourished, too much junk. 10= I'm getting everything I need from my nutrition

How warm or cold do you usually feel? *

1 3

1=I tend to run cold, 2=I'm pretty neutral, 3=I tend to run warm and overheat easily

How do you feel in terms of moisture and digestion? *

1 3

1=I feel heavy, bloated and tend to cary extra water, 2=I'm feel balanced, 3=I I feel dry, thirsty and prone to constipation

How does your body and nervous system usually feel? *

1 3

1=I'm tightly wound and tense, 2=I'm feel balanced, 3=I'm loose, tired, lethargic

Clarifying notes for the above if needed

Any questions or concerns?

Include sensitivities, preferences, dislikes, or anything else you'd like me to know.

How did you hear about us? *

Type your name to indicate understanding and acceptance of the below statement. *

I understand that Sarah Tacoma is a Clinical Herbalist and not a licensed medical doctor. This herbal recommendation is intended to support my health holistically based on my input and Sarah's clinical training in herbal medicine. This service does not include medical diagnosis or treatment. I understand: I should consult my doctor about any medical conditions or medications I’m taking. I am encouraged to share these herbal suggestions with my medical provider. A full herbal consult will provide more comprehensive care, including lifestyle and synergistic herb strategies. I am not obligated to purchase herbs through Bloem Botanicals. Any adverse reaction is not the responsibility of Bloem Botanicals or Sarah Tacoma.

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