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Comprehensive Wellness Initial Intake

SECTION 1 - CLIENT INFORMATION

Birthday
Month
Day
Year
Marital status
Single
In a relationship
Common-law or married
Seperated or divorced
Widowed

SECTION 2 - PRIMARY CONCERNS

Have you received a diagnosis related to this concern?
Yes
No
Are you willing to:
Is there any reason why you couldn’t take remedies made in alcohol?
Yes
No

SECTION 3 - HEALTH HISTORY

General - check all that apply:
Skin - check all that apply:
Lungs / heart - check all that apply:
Are you currently under medical supervision?
Yes
No

SECTION 4 - HORMONES AND URINARY

Check all that apply:
Are you:
Do you practice breast self-examination?
Yes
No
Not applicable

SECTION 5 - DIGESTION

Check all that apply
Bowel movements per day:
Less than twice a week
2-3 times a week
Every other day
Once every day
2-3 times per day
More than 3 times per day
Varies
How would you describe consistency?
Well-formed, easy to pass
Slightly hard
Hard / difficult to pass
Loose
Very loose
Alternates between hard and loose
Watery
Do you experience any of the following?
Do you experience bloating or abdominal discomfort?
Rarely
Occasionally
Frequently
Daily
Never

SECTION 6 - SLEEP AND ENERGY

How many hours of sleep do you average per night?
<5
5-6
7-8
8+
Sleep quality:
Do you wake during the night?
How do you feel upon waking?
Do you dream?
Energy dips occur:
Caffeine use:

SECTION 7 - STRESS AND NEUROLOGICAL

Do you feel your symptoms are connected to:
Have you experienced a significant life stressor in the past 5 years?
Yes
No
Work environment:
Check any that apply:

SECTION 8 - LIFESTYLE OVERVIEW

Do you drink alcohol:
Rarely
Sometimes
Often
Regularly
Never
Do you use drugs:
Rarely
Sometimes
Often
Regularly
Never
Do you exercise:
Rarely
Sometimes
Often
Regularly
Never
Do you skip meals:
Rarely
Sometimes
Often
Regularly
Never

SECTION 9 - INFORMED CONSENT

I understand that the services provided by Sea to Cells are educational and supportive in nature and may include holistic nutrition guidance, herbal and Ayurvedic-informed education, supplement recommendations, movement instruction, and therapeutic bodywork. These services are not intended to diagnose, treat, cure, or prevent any disease and are not a substitute for medical care.


I acknowledge that I am responsible for consulting my physician or qualified healthcare provider regarding medications, medical conditions, and any changes to my healthcare plan. I understand that herbs and supplements may interact with medications or health conditions, and I agree to disclose all relevant medical history and current medication


I voluntarily consent to appropriate professional touch during my sessions, and understand I may request modifications or withdraw consent at any time. I acknowledge that results vary and that my participation and choices are my responsibility.


I understand that my personal and health information will be kept confidential and stored securely in accordance with applicable privacy regulations, and will not be shared without my written consent unless required by law.


I voluntarily assume any risks associated with participation in these services and release the practitioner and Sea to Cells from liability for any outcomes related to my participation, except in case of gross negligence. I understand that services may be declined or I may be refrred out if my needs fall oustide the practitioner's scope of practice.

Date
Month
Day
Year
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