Evoke Healing Space - New Patient Intake Form

EVOKE HEALING SPACE INTAKE FORM
Full Name:*

First NameLast Name
Biological Sex:*

MF
Date:*

MonthDayYear
Date
Height:*
Weight:*
Phone:*
Email:*
example@example.com
Address:*

Address

Street Address Line 2

CityState

Postal / Zip Code
Occupation:
Retired Occupation:
Referred By:
HEALTH QUESTIONAIRE:
Are you currently in pain?

YesNo
Are you currently pregnant?
Please check any health issues you have experienced in the past 60 days.

BloatingDiarrheaHeartburnGasGalbadderGerdConstipationCandida/YeastRectal ItchingColitisBlack StoolsParasitic InfectionIBSBloody StoolsHemorrhoidsIBDWater-Like Grainy StoolsAbdominal PainDiverticulitisAcid RefluxTired After MealsDiverticulousStomach Ulcer
What products are you currently using on your face?
If there was something you could change or improve about your health, what would it be?
What would you rate your overall health?
What other health challenges would you like to change?
DIGESTIVE INFORMATION
Bowel Movement Frequency # of Times Daily:
Bowel Movement Frequency # of Times Per Week:
Must Strain?

YesNo
When was your last bowel movement?
What type of bowel movement best describes your current bowel shape below? Shape #:
List all of the prescription medications you are taking and why:
1. Medication Why? Why Do you Take This Medication?
2. Medication Why? Why Do you Take This Medication?
3. Medication Why? Why Do you Take This Medication?
4. Medication Why? Why Do you Take This Medication?
5. Medication Why? Why Do you Take This Medication?
List all the non-prescription medications such as aspirin, laxatives, antacids, supplements, vitamins, minerals, herbs, homeopathic formulas you are taking on a regular basis:
1. Medication Why? Why Do you Take This Medication?
2. Medication Why? Why Do you Take This Medication?
3. Medication Why? Why Do you Take This Medication?
4. Medication Why? Why Do you Take This Medication?
5. Medication Why? Why Do you Take This Medication?
List any surgeries you have had:
1.
2.
3.
4.
5.
Are you currently under medical care treatment?

Please explain the health issue and the care provider:
Health Issue(s):
Name of Care Provider:
Care Provider Phone#:
List any allergies you may have: (Food, environmental, etc.)
Evoke Healing Space uses Dr. Ben Johnson, MD’s revolutionary Skin Mapping approach. A thoroughly researched and clinically proven breakthrough that provides clear assistance in the analysis of the organs, toxins, and mechanisms involved in most common skin conditions. Each Skin Mapping facial zone represents an organ and the internal imbalances that often reveal themselves on the skin.

Please send the required 3 images below with your Intake Form so Evoke can begin evaluating your skin using the Skin Mapping method.
1. Front view of your face and neck.

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2. Right side of the neck and chin.

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3. Left side of the neck and chin

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I acknowledge that Dr. Ben Johnson, MD is the Medical Director of Osmosis Wellness and will be the medical director for his products and skin mapping procedures here at Evoke Healing Space.

I also acknowledge any information I receive from Evoke Healing Space or from Donna Kerley and staff of Evoke Healing Space is for educational purposes for informed decision making concerning my own health and wellness choices. I acknowledge they are NOT Medical Doctors, nor do they prescribe, treat or diagnose any illness or condition. I will not hold Evoke Healing Space, Donna Kerley, or any staff of Evoke Healing Space responsible for any choices or decisions I have made concerning my own self prescription of any treatments discussed and will not hold them liable for the results of those choices/ decisions. I agree to inform Donna Kerley and/or staff at Evoke Healing Space of any changes to my medications or health before any appointments I may have at Evoke Healing Space.
Client's Full Name:*

First NameLast Name
Signature*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

EVOKE HEALING SPACE INTAKE FORM

HEALTH QUESTIONAIRE:

DIGESTIVE INFORMATION