Hygeia Public Health Intake & Consent
Addendum to Flor da Vida general intake
for all programs under the guidance of Dr. Jill Diana Chasse
General Information
Full Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
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Month
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Day
Please select a year
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1920
Year
Due Date ( If Pregnant)
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
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1996
1995
1994
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1991
1990
1989
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1982
1981
1980
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1978
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1972
1971
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1964
1963
1962
1961
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1958
1957
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1955
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1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Program or Session Interest
Resolve (6 week program)
Living Lokahi (6 week program)
Lomi Body-Energy work individual session(s)
HeartMath individual session(s)
Functional Labs
Other
Needs
Relaxation/Stress Reduction and Management
General Mental Health Support
Perinatal Mental Health Support
Fertility
Birth Trauma
Other Trauma
Birth Preparation
General Functional Medicine Labs and Testing
Lomi Body/Mind/Energy Work
Other
E-mail
*
example@example.com
Phone Number
*
Pronouns
How did you hear about our services?
In our Lomi work, we often use pule, a form for chant/prayer. Are you opposed to the of this form of meditation?
Were/are there any emotional traumas in your early or present life? (ie. rape, loss, suicide, death of a loved one, etc.)
Please explain as much as you feel comfortable
Medical History
Are you under the care of a qualified healthcare professional? Please list whom.
*
Prenatal Disclaimer: Labor-stimulating techniques or any labor-inducing substances will not be used unless the treatment is specifically for the induction of labor. The treatment intended to induce labor requires a letter from a primary care provider authorizing or recommending such treatment.
*
I acknowledge
not pregnant
Do you have any allergies/aversions to oils, lotions, or ointments?
*
What medications, supplements and over the counter items do you take regularly or are currently prescribed:
*
Any past surgeries and hospitalizations?
*
Stress in work, family, or other aspects of life affects you in the following ways:
Muscle Tension
Anxiety/Panic Attacks
Sleep Problems
Anger Management
Irritability
Other
Personal History
Have you used biofeedback previously?
What is your opinion of yourself?
Do you currently have any physical health concerns?
describe
Do you currently have any emotional health concerns?
describe
You have problems falling or staying asleep?
Do you wake up refreshed?
How many hours do you sleep?
How is your energy level? on a scale of 1 - 10
Does your energy level affect your daily activities?
How would describe your mood, generally:
Does your mood affect your life or daily activities?
How would you describe your stress level?
What are your sources of stress?
How do you manage stress?
Do you have people close to you who support you?
Are you interested in doing psychological/mental health screening?
Yes
No
Can we talk about it
Diet and lifestyle
Do you regularly drink alcoholic beverages?
If yes, how many per week?
Do you smoke tobacco?
Please Select
Yes, 1+ pack per day
Yes, 1/2 pack per day
Yes, less than 1/2 pack per day
I have quit
I have never regularly smoked
Do you use recreational drugs?
How is your appetite?
How many meals per day do you eat?
Are you interested in working on a diet plan?
Please list any food allergies, intolerances or foods you avoid and the reason.
Are you interested in food allergy testing? (we currently us RUPA labs https://labs.rupahealth.com/discover-labs/search)
yes
no
not at this time
Let's get a current picture of your health
Health History
*
No, never
Yes, currently
Not currently, but I did previously
Fatigue
Unexplained weight loss or gain
Change in appetite
Depressive symptoms
Anxiety
Mood swings
Nervousness
Addictive dependency
TMJ
Tension
Lack of mental focus
Thyroid problems
Diabetes
Blood sugar irregularities
Tendonitis
Excessive perspiration
Feeling excessively hot or cold
Headache
Lightheadednes
Joint pain or stiffness
Muscle weakness or soreness
High blood pressure
Heart murmur/palpitations
Cold or pale extremities
Asthma
Short of breath
Heartburn
Back/neck problems
Nausea
Abdominal bloating
Open sores/wounds
Constipation
Uterine issues
Contagious infection
If I am currently having or I develop complications (any conditions/symptoms listed above with ) I will disclose the condition with Dr. Chasse.
*
I acknowledge
Pregnancy Specific Symptoms (skip if this doesn't affect you)
Never
Previously
Currently
Miscarriage
Abortion
Preterm delivery
Stillbirth
Placental issues
Preeclampsia or HELLP
Gestational diabetes
Uterine bleeding
PMAD
Would you like me to contact/ share information with your Primary Care Provider?
Yes
No
Not at this time
Other
Contact Information for Provider
example@example.com
Practice or Practitioner Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
We cannot work on you (or need a release from your primary provider) if any of the following are checked:
you need a cesarean (depending on reason)
you have had vaginal bleeding in the previous 7 days
the baby’s heart rate is not normal
you have an unusually shaped uterus
you recently had vaginal bleeding
low amniotic fluid (oligohydramnios)
you have placenta previa
you have ruptured membranes
Just one last box to write here anything important that you'd like me to know before we begin.
I have completed this health form to the best of my knowledge. I understand that Dr. Chasse is a specialist and does not take the place of a primary physician or midwife's care. Any information exchanged is confidential and is only used to provide you with the best health care services. I have received and signed Dr. Chasse’s and/or Flor da Vida’s disclosure (please sign with your cursor below). (Acknowledgement and Consent to Privacy Practices and Consent to Limited Treatment are through Flor da Vida).
*
Submit
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