Health Form - Workshop — EarthStar.Birthing

Insight Herbalism - health questionnaire

We ask you to give us some basic health information to ensure that there are no contraindications when working with the plants.

Please complete this form prior to the retreat.

Thank you

All information will be kept safe and confidential. All information will be viewed in a compassionate and non-judgemental capacity.

Any queries please get in touch

Emily - 07889996477 / emily@earthstar-birthing.co.uk

Name

First Name

Last Name

Email

Please tell us about any significant medical conditions and any medication you are on:

Do you have any allergies or any reason to believe you may be allergic to a plant:

Do you have any experiences of mental health challenges either past or present:

Are you pregnant or Breastfeeding:

Do you have a sensitivity to Alcohol

Some teas are made using tinctures which contain alcohol, which will evaporate when mixed with boiling water, but do let us know if you need to avoid alcohol completely, and we can accommodate.)

Yes

No

Would you like to be added to my mailing list

Yes

No