Wyldwood Sanctuary Intake form

Medical History (check all that apply)

	Past	Current
Anxiety/Stress
Asthma
Arthritis
Allergies
Autoimmune disease/poor immune function
Blood: clots/disorder
Cancer
Chiari Malformation
Chronic pain
Circulatory condition
Concussion
Covid-19
Covid long haul or other complications

Have you had a Covid-19 vaccine?*
If yes, when?
List vaccination dates
Have you had a recent Covid booster?*
If yes, when?
List latest booster date
Recent injuries and surgeries
Previous injuries and surgeries
Please list any significant physical and/or emotional trauma you've experienced in your life:
Current Medications
What is your current stress level?*
Current stress reduction activities:
What is your current pain level?*
Pain duration*
Have you used other complementary therapies?*
Did you experience any uncomfortable or adverse reactions to any of these therapies?*

Anything you want to add or clarify?*
All client information shall be held in strictest confidence except where required by law.

Click here to read Wyldwood Sanctuary's policies before accepting and signing the agreement below.
Client Agreement:

I Your name*, have read, understand, and agree to Wyldwood Sanctuary's appointment rescheduling, cancellation, and payment policies.

I understand that craniosacral therapy and restorative mind-bodywork therapies should not be construed as a substitute for medical examination, diagnosis, or treatment. Because craniosacral therapy and restorative mind-bodywork should not be performed under certain circumstances, I affirm that I have stated all medical conditions of which I am aware. And I agree to inform my practitioner of any changes in my health and medical status and understand that there shall be no liability on the practitioner's part should I fail to do so.
Signed on*

MonthDayYear
Date
Signature

Clear
rev 9/2022
Should be Empty:

	Past	Current
Depression
Disk problems (herniated, bulging, degenerative, broken, fused)
Diabetes
Digestive issues/GERD (reflux)
Ehlers-Danlos syndrome (EDS)
Fibromyalgia/Chronic Fatigue
High blood pressure
Heart Attack/Heart disease
Hearing impaired
Hepatitis
HIV/Aids
Headaches: migraine
Headaches: non-migraine
Hormone imbalance/Menopause
Infection (current status only)
Injuries (list on next page)
Joint pain, swelling, replacement
Lupus, SLE
Lymphedema/edema
Memory problems, foggy brain
Multiple Sclerosis
Numbness. tingling, neuropathy
Neck/back/spine problem or pain
Osteoporosis/Osteopenia
Parkinson's Disease
Pregnancy/C-section, abdominal surgery
POTS
PTSD
Skin problems/rash
Staph/MRSA
Stroke/TIA
Surgery (list on next page)
Seizures
Sinus problems
Sleep issues: apnea, insomnia
Trauma: physical
Trauma: emotional
Trauma (unknown origin)
Thyroid/endocrine disorder
Vertigo/Dizziness
Whiplash
OTHER (list below)