Mind-Body-Spirit Medicine Intake & Release Form

CONTACT INFORMATION
Today's Date
Today's Date
Name *
Name
What name would you like me to call you?
Legal Name
Legal Name
What is your legal name, if different?
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
It's okay to contact you by *
Their name, your relationship to them and their phone number
PRACTITIONER INFORMATION
It's helpful to know if you are under the care of other practitioners. Sometimes it is possible to coordinate care, with your consent.
Are you under the care of another healthcare provider? *
Including naturopaths, acupuncturists, therapists, etc.
Please include the name, type of practitioner, address and contact information for them.
INTENTION-SETTING
What do you attribute this to?
If you receive Maya abdominal massage, you understand that we will be working right off the pubic bone on the front and the tailbone on the back. Is this okay with you? *
If you receive Holistic Pelvic Care, you understand that we will be working intravaginally with the connective tissues of your pelvic bowl. Is this okay with you? *
EAST ASIAN MEDICINE QUESTIONS
See the descriptions under each question and please give a detailed response to each category.
Do you tend to run cold or hot? Do you experience... Night sweats? Hot flashes? Cold hands and/or feet? Chills?
How is your overall energy? Do you tend to feel tired or energized? What times of day are you at your peak energy and lowest energy?
Do you tend to sweat easily (without exertion)? Do you sweat with exertion? Do you sweat profusely? Is there a particular odor to your sweat?
How many hours a night do you sleep? How is the quality of your sleep, ie do you wake feeling rested? Do you have trouble falling asleep or staying asleep? Do you have recurring dreams or themes in your dreams?
Do you tend towards dry skin? Do you experience rashes, eczema or other skin-related conditions? If so, do you know what triggers these?
Do you experience pain? If so, where, how frequently and at what severity? Do your pain impede your day to day living? If so, how?
HEADACHES Do you get headaches? If so, how often? Where is your headache felt (front / back / sides / top of head)? What is the severity of your headaches? Do you have a history of traumatic brain injuries? If so, when was this and how severe? EYES How are your eyes? Do you ever get burning or itching? How is your eyesight? EARS Do you have any hearing issues? Tendency or history of frequent ear infections? NOSE Do you have any sinus issues, such as congestion? Any other issues related to your nose? MOUTH Do you tend to have a dry mouth? Do you have dry lips? Any other issues related to your mouth?
HEART Do you experience chest pain? Chest tightness? Palpitations (feels like heart fluttering / skipping a beat)? Dizziness? Shortness of breath? LUNGS Do you have any respiratory issues? Do you frequently get colds or respiratory infections?
How is your digestive health? Do you tend to have ... Pain in your abdomen? Gas? Bloating? Burping? Nausea? Heartburn?
How is your appetite, in general? Do you experience a lot of hunger or little hunger? What flavors and textures do you crave? Do you tend to be thirsty? How many 8-oz cups of water do you drink daily?
How many times a day do you have a bowel movement? Do they feel complete? Do you tend towards constipation / diarrhea / mixed? Do you have blood or mucous in your stools?
Do you urinate about equal to the amount of fluids you drink? If not, do you urinate less or more? Does your urine have a particular odor (beyond typical smell)? Is it light and pale or darker in color? Any blood in your urine? Pain with urination? Urinary leakage? Do you wake up in the night to urinate?
MENSES Do you get a menstrual period? If so, how long are your cycles and how many days do you bleed? How heavy are your periods? Pain with menses? If so, is this before you start bleeding, during or at the end of your bleeding? REPRODUCTIVE HX Are you currently on hormonal birth control or IUD? Any abdominal surgeries? History or current experience of any gynecological imbalances? If so, what exactly?
GENERAL MEDICAL HISTORY
Include years when possible, and if you are undergoing treatment currently for this condition. Include allergies to oils, fruits or nuts, if relevant.
HISTORY OF BODY & EMOTIONAL SAFETY
The following questions are of a sensitive nature. Only answer what you feel comfortable answering. Our bodies tend to store held emotions that may start to "wake up" as we access them in mindfulness. Because of this, it is helpful for us to know your history so that we can create the safest and most respectful environment possible for you.
Have you had a traumatic experience (sexual, physical, emotional, verbal or otherwise)?
Do you or your family have a history of substance use? If yes for you: How much & how often? What does it do for you? Have friends/loved ones expressed concern? Have you ever felt you need to chose your substance over basic necessities of life (rent, food, etc)? Any history of negative consequences associated with use? (Hospitalization, arrests, relationship issues)?
Do you think often about suicide? Do you have a plan? Have you ever attempted suicide?
Have you ever been hospitalized for a psychiatric condition? If yes, when, for how long and why?
LIFESTYLE, EMOTIONAL & SPIRITUAL
If personally meaningful for you, describe how you culturally identify. How do you relate to your culture(s)?
Share a few words about your family of origin and your home environment growing up. We will have time to explore this in session. This can be a small introduction so I can know a little more about where you're coming from. Please include any psychological and medical conditions.
Describe your relationship status and/or support network. How are your relationships?
CONSENT & RELEASE
I am aware of the contraindications of various modalities that may be practiced listed below. By signing this form, I agree that they do not currently apply to me. You should NOT these modalities if the following contraindications apply to you ❂ Severe mental illness ❂ A mental health emergency ❂ Sever effects of trauma that may do better with more specific counseling modalities
Please take a moment to carefully read the following information and sign by typing your initials below. If you have a specific medical condition or specific symptoms, any of these modalities may be contraindicated. A referral from your primary care provider may be required prior to service being provided. I understand that if I experience any pain or discomfort during any session, I will immediately inform the practitioner. I further understand that these modalities should not be construed as a substitute for medical examination, therapy, diagnosis, or treatment and that I should see a physician, therapist or other qualified medical or counseling specialist for any physical or mental ailment of which I am aware. I understand that the practitioner facilitating the healing is not qualified to diagnose, prescribe, and/or treat any physical or mental illness, and that nothing said in the course of any session given should be construed as such. Because each of the above named modalities should not be performed under certain medical conditions, I affirm that I have stated all of my known medical and psychological conditions, and answered all questions accurately, completely, and honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I forget to do so. I understand that I am proceeding to receive any of these healing modalities at my own risk and hereby release Jeevan Singh from any liability.