Boulder Jaguar Salon Intake Form
Thank you for completing this form as part of our work together. We ask for this to be completed to screen for contraindications.
Name
*
First Name
Last Name
What is your Gender?
*
Female
Male
Nonbinary
Prefer not to say
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address (Protonmail is preferred - encrypted free e-mail service)
*
Protonmail is free and preferred for communication about medicine work and allows us to communicate openly through secure encryption)
How did you hear about us? Who referred you to us?
*
How did you hear of us? Who referred you to us?
*
Medical Conditions - Please check all that apply
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Asthma, COPD
Cancer
Chest pain or Angina
Cardiac disease, Heart attack, Coronary Artery disease, Heart failure
Diabetes
Hypertension / High blood pressure
Psychiatric disorder
Epilepsy or seizure disorder
Pregnant
Heart arrhythmia
Stroke
Liver or Kidney Failure
Head Injury / Concussion
Aneurysm
None of the above
Food Allergies
Other
Please offer details of any conditions above, including dates and any ongoing treatments.
*
Are any of these present for you currently or in the past?
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Suicidal thoughts or attempts
Difficulty trusting others
Anxiety
Depression
Poor memory
Feelings of loneliness
Hot temper
Easily stressed
Excessive worry or rumination
Nervousness
Paranoia
Post Traumatic Stress Disorder
None of the above
Please provide details about any item you checked above:
*
Trauma plays a major role in the work that we may do together and can arise as an aspect of these sessions. Please describe the impact of trauma on your life and how you have worked with it to this point.
*
Are you currently taking any prescription (Rx) medicines?
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Yes
No
Please list all medications, amount, length of use and the condition it is prescribed for:
Example: Prozac, 20mg, twice daily, since 2014, Depression
Are you currently taking any of the following categories of medications? This is particularly pertinent to the work we may do together:
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SSRI (Paxil, Zoloft, Celexa, Lexapro, Prozac, Luvox)
MAOI (Nardil, Marplan, Parante, Moclobemide, Emsam)
SNRA (Effexor, Cymbalta, Pristiq, Fetzima)
DNRI (Wellbutrin)
Tricyclic Antidepressants (Elavil, Pamelor, Anafranil, Tofranil, Norpramin, Chlorpheniramine)
SPARI (Vilazodone, Vortioxetine)
Lithium
Anticonvulsant Mood Stabilizer (Valproate, Lamotrigine, Carbamazepine, Oxcarbazepine, Gabapentin, Topiramate)
Antipsychotics (Abilify, Saphris, Zyprexa, Risperdal, Seroquel, Geodon, Latuda)
None of the above
Do you use marijuana (any form)?
Yes, daily
Yes, multiple times a week
Yes, occasionally
No
Do you currently, or within the last two years, use tobacco in a habitual way?
*
yes
no
How often do you consume alcohol?
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Daily
Weekly
Monthly
Occasionally
Never
Please describe your experience with altered states of consciousness. What medicines or practices have you worked with and in what capacities?
Please provide an emergency contact and their relation to you (ie, partner, spouse, family member).
*
Please provide a contact number for this person.
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is there anything else that you would like me to know about you that could help me provide you an amazing and transformational experience?
Submit
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