Stirred Water Herbs  

Helpful Information

Visit Our Store

307 S. Durham Hwy

Acra, NY 12405

Tel: 518-929-8228

Mon - Fri:    8am - 5pm

​​Saturday:      9am - 2pm

​Sunday:         Closed

Other Hrs:   By Appt.

(C) 2018-2019 Stirred Water Herbs

Intake Questionnaire 

I think it would help if you included an explanation of why this is important!

This questionnaire is to help you and I understand your health concerns.  If you prefer not to answer a question, please leave it blank. You are not obligated to complete this form.

User keys to online intake form, that loads spreadsheet database, which will ultimately be accessible via owner-only web pages.

arrow&v
arrow&v

Please check the types of health care practitioners you have seen or are seeing.

Chiropractor

Naturopath

Counselor

Massage Therapist

Herbalist

Medical doctor

Homeopath

Occupational Therapist

Psychiatrist

Psychologist

Social Worker

Other

Check if you've had recent bloodwork done, and please bring a copy of the results with you to our visit.

arrow&v
0
  • Latest Info