Living Lokahi Intake Form
Welcome! Our program recognizes the importance of a multi-dimensional approach to health. You will explore how various factors - from physical health and nutrition to mental, emotional, and spiritual well-being - interplay and contribute to overall health. Let's begin by answering some questions about your health and wellness.
Date Today
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Month
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Day
Year
Date
Personal Information
Name
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How do you envision your best health?
We will focus on spirt, mind, body, heart, earth, and community. Combining traditional ways with modern medicine can enhance resilience, protect against chronic disease, and strengthen the health of our communities. Are you in line with this vision?
Are you currently pregnant?
Yes
No
Emergency Contact Person
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
Health Information
In Living Lokahi, we will examine the root causes of multidimensional disease and dysfunction from a functional medicine perspective. You’ll explore the interconnectedness of the body’s systems as you revisit your own health story and learn to listen to and honor your needs. Think about where you are now and where you would like to be. For each box below, on a scale of 1 (low) to 10 (high), how would you rate each lifeway?
Where I am NOW
Where I would LIKE to BE
Nutrition-
Consume a natural diet, free from processed foods
Physical Activity
Rest and Sleep
Connection with Nature
Connection with Spirit/ Universe
Connection with Community
Health and Medical Care-
Seek regular preventive care and practice healthy behaviors
Physical Health related questions
Yes
No
Remarks
Do you have a broken bone?
Do you have strains or sprains?
Are you using a cane or crutch?
Have you been hospitalized due to injury?
Have you undergone any surgery?
Do you have any allergies?
Are you taking any medications right now?
Emotional/Psychological Health related questions. Rate how well, or how frequently, you believe that you engage in each activity
I rarely do this/ I don’t do this well
I sometimes do this / I’m average at doing this
I do this often / I do this very well
I’d like to do this more often/ I’d like to become better at this
Enjoying hobbies
‘Unplugging’ from technology
(e.g. email, social media)
Learning about or exploring new things
Practicing self-nurturing activities
(e.g. long bath, gentle walk)
Laughing about things
Expressing emotions and feelings
(e.g. talking, journaling)
Taking a holiday, escape, or mini-break
Appreciating own talents,
accomplishments, and strengths
What challenges or barriers have you previously encountered that have prevented you from reaching your health goals?
Do you feel any pain or physical discomfort in your body?
Yes
No
If answered yes, where do you feel the pain?
What part of the body?
How do you describe the pain?
Stabbing
Aching
Burning
Numbness
Pins & Needles
Other
Are you currently working with a health provider for your symptoms?
yes
no
Other
Review of Systems
Normal
Not Normal
Notes/Remarks
Sensory (Eyes, ears, nose, throat)
Musculoskeletal (Mobility)
Integumentary (Rashes, irritation, pale)
Neurovascular (Paint, seizures, sensation)
Circulatory (Skin, edema)
Respiratory (Shortness of breath)
Dental (Dentures)
Psychosocial (Hallucinations, delusions)
Nutrition (Diet, weight change, swallowing)
Elimination (Constipation, incontinence)
Family History Illnesses
Asthma
Cardiovascular Disease
Diabetes Mellitus
Hypertension
Migraine Headaches
Mental Health issues
Cancer
Other
List all the medications and/or supplements that you are currenty taking and the amounts of each
Do you have any emotional discomfort at this time? If so, please explain
Please check all symptoms that are currently affecting you
Excessive guilt
Fatigue
Decreased libido
Racing thoughts
Impulsivity
Risky behavior
Excessive energy
Increased irritability
Crying spells
Excessive worry
Anxiety attacks
Avoidance
Hallucinations
Suspiciousness
Suicidal thoughts
Self-harm
Other
Are you currently working with a mental health provider for your symptoms?
Yes
No
Yes but it is not helping
Yes but I need additional support
Other
If you had difficulties in the past, what have you done to cope? Was it helpful?
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.
Date Signed
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