In order to align yourself wholistically (mind/body/spirit), it is necessary for you to be as accurate as possible when filling out this form. The information received will help determine the best possible approach to guide you through your journey of total transformation. The Plant Lady Juice Co. Wholistic Consultation will assist you in learning how to heal yourself, in order to maintain optimal levels of wellness.

Are you interested in an in-person or virtual consultation? *

In-person
Virtual

Full Name *

Phone *

Email *

Street Address *

Address line 2

City *

State *

Postal / Zip Code *

Country *

Do you have any allergies? *

Yes
No

If yes, what are they?

List all food, medications, and external allergens.

Are you pregnant or breastfeeding? *

Yes
No

Are you currently taking any medications, supplements, and/or herbs? *

Yes
No

If yes, what are they?

(prescribed, recreational, and/or over-the counter)

Do you have any current medical diagnosis? *

Yes
No

If yes, what are they?

Do you often feel more hot or cold? *

Hot
Cold

Does the hot/cold feeling differ through the day/night? *

Yes
No
Sometimes

Body System Health Profile

Please carefully select all major and minor areas of concern. Leave blank if not applicable.

Circulatory System

Respiratory System

Digestive System

Eyes, Ears, Nose & Throat

Eye Pain (Wet/Dry)
Failing Vision
Ear Aches
Hearing Loss
Ringing in the Ears
Hay Fever
Tonsils
Other

Skin

Boils
Acne
Eczema
Psoriasis
Bruise Easily
Herpes Simplex
Slow Wound Healing
Other

Male Reproductive System

Female Reproductive System

Menstruating

Irregular Menstrual Cycles
Heavy Menstrual Cycles
Painful Menstrual Cramps
Bleeding Between Cycles
Absence of Menstrual Cycles
Dramatic Mood Swings (around cycle)
Lack of Sex Drive
Other

Menopausal

Hot Flashes
Dramatic Mood Swings
Dry Vaginal Lining
Osteoporosis
Vaginal Bleeding
Estrogen Replacement Therapy
Lack of Sex Drive
Other

Endocrine Glands

Immune System

Auto-immune Disease
Chronic Fatigue Syndrome
Fibromyalgia
Neuralgia
Frequent Colds
Vaccinations
Other

Lymphatic System

Congestion
Swollen Glands
Infection
Drainage
Other

Nervous System

Past Medical History

Please list any operations you have had with date, including appendectomy, tonsillectomy, etc:

Please list any major injuries/accidents, including date:

Please list any traumatic experiences not treated medically (divorce, loss of job, death of loved one, etc)

Family Medical History

Maternal Medical History

Paternal Medical History

Sibling Medical History

According to my bloodline, I am:

BIPOC
Ally

Please read our disclaimer and check the box below to agree to our Terms and Conditions prior to submitting your Wholistic Consultation Form.

I agree Terms and Conditions *

Wholistic Consultation Form

Body System Health Profile

Past Medical History

Family Medical History

Thanks for getting in touch!

Thanks for getting in touch!

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