Medical History Form

Contact & Health Screening

Welcome to a world within ~ please fill out our health and screening form. We're deeply committed to the safety, health and well being of those we deem a good fit for our services and do a full health screening to make that determination using the best resources available to us. By having a clear idea of the journey life has given you we can see how best to give you a journey that works for you. Together, we are committed to weaving a tapestry of intention, nourishing the highest potential in ourselves and others as we surrender to the flow of source consciousness through divine will. (The information provided is confidential)
Filling out the form in full with give me a chance to review before our discovery call. It isn't necessary and you can simply provide your contact information. We can do the health screening over the phone if preferred, though it is required so that we both have informed consent regarding any safety concerns in working together.
Full Name

First NameLast Name
What is your age?
Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number
Email Address
example@example.com
How did you find us?
Would you like to be informed of future sessions via email, text and/or Signal Group?

EmailTextSignal Group
What services are you interested in? (Each session will be available once monthly)*

1:1 ~ Solo Soiree CeremonyGroup ~ Deep Dive Ceremony1:4 ~ Circle of 5 Ritual (Requires previous experience)Wombology ~ Blindfolded Dance Workshop (Less than monthly)Wombology ~ Sighted Safety and/or Facilitator Training
Would you be interested in assisting as a space holder in ceremony?

YesNoMaybe in the future
Is there anything you'd like to share about your intention, desire or what you are looking for?
Physical and Mental Health Questionnaire

Please read and answer questions with care and honesty based best on your personal health: Check YES or NO.

Cardiovascular Issues / Diseases

	Yes	No
Heart Attack
Angina
Irregular Heart Beat or Arrythmia
Deep Vein Thrombosis (DVT)
Blood Clots
Significant High or Low Blood Pressure

Blood Borne

	Yes	No
Diabetes
Hepatitis
HIV / Aids

Respiratory Issues

	Yes	No
COPD
Chronic Bronchitis
Asthma
Phemonia
Emphysema

Neurological Health

	Yes	No
Stroke
Transient Ischemic Attack (TIA or mini-stroke)
Aneurism
Epilepsy
Seizures
Recent Head Injuries
Concussions or Bleeding Brain Lesions
Anything else affecting the brain, nerves, or spine?

If yes, Please share here:

Mental Health *Relevant to Personal and Family*

	Yes	No
Schizophrenia
Psychosis
Manic- Depression
Bi-polar Disorder
Borderline Personality Disorder
Dissociative Identity Disorder
History of Suicide
Obsessive Compulsive Disorder
PTSD or CPTSD
General Anxiety
General Depression

Psychiatric Medications

	Yes	No
(SSRI's) Selective Serototin Reuptake Inhibitors
(NDRI's) Norepinephirine Dopamine Reuptake Inhibitors
Tricyclics
(MAOI's) Mono-amine axidase Inhibitors

Please list any medications (Prescribed, Over-The-Counter, Vitamins, and Herbal Supplements)
Do you have any medication allergies?

YesNoNot Sure
I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction
Initials

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Date

MonthDayYear
Thank you for completing this health screening truthfully and to the best of your abilities. Know that this information is confidential and will not be shared. Please ensure your phone number is accurate on this form and we will reach out to you directly via email with a few options to meet for our discovery call. May curiosity guide you ~ may gratitude hold you on your path. We look forward to connecting with you.
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Contact & Health Screening

Physical and Mental Health Questionnaire