Spapothecary Intake & Consent

Spapothecary from Physio Body Holistics

Intake and Consent
Date*

MonthDayYear
Date of Appointment
*

First NameLast Name
Your 4 Target Systems
For Office Use
Extra Notes
For Office Use

Which Treatments Are You Interested In?

	Treatment
Hydrotherapy
Steam
Facial
Sauna
Massage
Movement
Thallasotherapy
Corrective Therapies
Wellness Program

Intake*

	Answer
Do you have Low or High Blood Pressure?
Skipped Heart beats or heart palpitations?
Have you been diagnosed with any type of heart weakness?
Do you have asthma or allergies?
Do you get bronchitis easily?
Have you ever had a lung infection or virus that effected your lungs?
Do you have hypoglycemia, hyper or diabetes?
Have you been diagnosed with a thyroid condition?
Do meals give you energy or make you feel tired after eating?
Do you have joint or muscle pain or weakness?
Do you suffer from muscle cramping?
Do you ever get dry skin during the winter ?
Have you ever suffered from eczema or other skin related issue?
Do you get anxiety easily?
Do you have trouble sleeping?
Do you get tension headaches?
Do you suffer from stomach pain?
Do you get gas or bloating after eating and what?
Do you suffer from constipation?
Do you sweat easily?
Do you suffer from oily hair or dandruff?
Do you suffer from dry eyes?
Do you still have your period if so is it regular?
Is it heavy, normal or infrequent?
Do you suffer from PMS and if so to what degree?
Have you had a fracture in your life?
Are you hypermobile or lack of flexibility?
Have you been diagnosed with osteoporosis or penia?
Do you have any fillings or dental work?
Do you have chronic neck or back pain?
Are you experiencing extreme reactions to certain foods?
Are you intolerant to cold or heat where your loose circulation or get dry?
Do you have a family history of autoimmune disease?
Do you tend to fatigue and get headaches in the afternoon and then get a second wind in the evening?
Do you feel dizzy when you stand up suddenly?
Do you crave salty foods?
Are your hands and feet often cold even it is warm out?
Do you sleep excessively or feel like you could sleep more?
Are the outer thirds of your eyebrow thinning or missing?
Has your sex drive disappeared?
Extra Notes

I understand that this is an educational herbal consultation for the purpose of helping me improve my health and wellness. I understand this does not include medical diagnoses or treatment and is not a substitute for medical care or an agreement for ongoing care.

Please Initial Each Box After Statement*

	Treatment
The human body has the innate power to heal itself. Without this power to self-heal, even the most advanced medications and surgical procedures would ultimately fail. I understand that the role of the herbalist in this healing process is to consider the client as a whole person and to consult with the client concerning changes in lifestyle, diet, and supplementation of herbs and/or vitamins to foster an increased state of balance and health, thus maximizing the body's self-healing capabilities.
Nutrition related assessment, diagnosis, and therapeutic methods based on the healing system are practiced. This scope of practice includes dietary assessment, dietary changes, physical diagnosis, interpretation of laboratory values relating to nutrition, dietary counseling, reviewing medical records, recommending diet therapies, recommending nutritional supplements when indicated, recommending treatments to emphasize the self-healing process, and identifying proper treatment strategies.
It is understood that I am NOT a medical doctor and do not practice western medical assessment, diagnosis, or treatment. I do not claim to cure disease. Nor do I give advice about pharmaceuticals and medications at any time. I have no objections to clients being seen or evaluated by their own medical doctor. Questions and concerns about your condition are highly recommended to be discussed with your primary care physician. We are willing to work as part of a health care team, and recommend you inquire and explore any recommendations we provide with any professionals in health care. HIPPA privacy regulations allow your information to be held confidential and not shared with anyone.

Signature & Date*
By Signing above I understand, have read & completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications from services received. The treatments I receive here are voluntary and I hold harmless and release all professionals who work for Physio Body Holistics & The Acropolis Institute of Naturopathy from liability and assume full responsibility thereof.
Should be Empty:

Bladder/Genitourinary
Blood
Liver/Gallbladder
Digestion
Spleen
Female Reproductive
Heart/Cardiovascular
HPA axis/Endocrine System
Immune
Kidney
Large Intestine
Lung/Respiratory
Lymphatic System
Male Reproductive
Mucous Membranes
Musculoskeletal
Nervous
Pancreas
Skin/Peripheral Circulation
Small Intestine
Thyroid/Parathyroid

Spapothecary from Physio Body Holistics