Medicinal Plant Collection Data Sheet: collection # _______ day--month--year___________/____________/_____________time (2400)__________________ collection site: temperature_________o C F altitude___________ meters feet GPS coordinates: ______o______²______¹ latitude ______o______²______¹ longitude interviewer___________________________________________________________________ translator (if any) _______________________________________________________________ person interviewed (informant)________________________________________________ location of informant ____________________________________________________Costa Rica birthplace of informant ___________________________________________________________ background & training of informant_________________________________________________ _____________________________________________________________________________ name(s) of plant (language)_____________________________________________________ scientific name (if known)_________________________________________________________ date, time (if different from above) plant collected______________/____________/____________ medicinal use(s) of plant 1______________________________________________________ 2_____________________________________________________________________________ 3_____________________________________________________________________________ 4_____________________________________________________________________________ not used in: pregnancy children aged debilitated plant collection: location/identification_____________________________________________ ______________________________________________________________________________ collection # ___________ must plant be used fresh? Y N how long can dried plant be used? ________days months indef season plant should be collected: w sp su f any preferred time of day: am pm night any part of plant collected: seeds fruit flowers leaves stems bark sap rhizome root whole other ________________________amount needed for a course of treatment__________________ Initial preparation of plant material: dry wash scrape shred grind mince use whole extraction: solution used: water ethanol oil other________________________________ amount used ______________________oz cups ml liters temperature/time of preparation: cold ambient hot boiling ________hours__________min additional preparation: strain decant reduce dry other _______________________________ administration of plant medicine: amount: _______drops _________tsp_________cup(s)________liters_______oz________mg how taken: __________ times/day for ___________days for condition(s) # 1 2 3 4 (see p.1) special instructions: ______________________________________________________________ take with ______________________________________________________________________ avoid_________________________________________________________________________ may cause: nausea vomiting diarrhea constipation rash itching drowsiness restlessness other side effects________________________________________________________________ ______________________________________________________________________________