| Herbal Preparation | √ box if taking |
Date Started (mm/yyyy) |
| Ex: St. John’s Wort | 03/1997 | |
| Glucosamine | ||
| Chondroitin | ||
| Omega-3 fatty acids | ||
| Coenzyme Q10 | ||
| Black Cohosh | ||
| Garlic | ||
| Echinacea | ||
| Sasparilla | ||
| Cat’s Claw | ||
| Red Clover | ||
| Fo Ti Teng | ||
| Alfalfa | ||
| Fenugreek | ||
| Seaweed (kelp) | ||
| Milk Thistle | ||
| Astragalus | ||
| Mushrooms (maitake, shitake, etc.) | ||
| Turmeric | ||
| Essiac | ||
| Digestive enzymes | ||
| Ensure or Boost | ||
| Carnation Instant Breakfast | ||
| Don quai | ||
| Ginko biloba | ||
| Ginseng | ||
| Green Tea (tea or extract) | ||
| Bee Pollen | ||
| Royal Jelly | ||
| Saw Palmetto | ||
| Shark Cartilage | ||
| Soy | ||
| St. John’s Wort | ||
| Valerian | ||
| Wild/Mexican yam | ||
| Yerba Buena | ||
| Acai Juice | ||
| Flaxseed Oil | ||
| Fish Oil | ||
| Other:_______________ | ||
| Other:_______________ | ||
| Other:_______________ |
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