Rooted Traditions, Leaf and Medicine

Client Intake and Consent

Please complete this form as accurately as possible. Your answers help us understand your wellness goals, relevant history, medications, supplements, and lifestyle factors.

A. Client Information

B. Main Reason for Consultation

C. Current & Past Health History

D. Family History

E. Medications, Herbs & Supplements

List prescription medications, over-the-counter products, vitamins, minerals, herbs, and supplements.

F. Allergies & Sensitivities

G. Women's / Reproductive Health (if applicable)

H. Digestion & Bowel Health

I. Diet, Hydration & Stimulants

J. Sleep

K. Stress, Mood & Activity

L. Client Safety Acknowledgement

Please confirm the following before signing.

Client Informed Consent · Scope · Risk · Liability & Fee Agreement

Practitioner: Radha Krishna Singh, Intern Herbalist, MBA.

Your typed name and date above will be included as your signature in the completed intake PDF.