Mountain Sage Health Intake Form

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Please complete the following confidential health history in order to provide me with your current health status to ensure you receive comprehensive care. This form needs to be filled out BEFORE your Personalized Wellness Consultation with Aimee Williams, CCA.

Email *

Client Name & Address *

Phone Number *

Date of Birth *

YYYY

Marital Status *

Emergency Contact Name & Phone Number *

Occupation *

Are you currently being treated for a diagnosed medical condition? Please explain *

Primary Medical Professional

Please list any physician- or self-prescribed medications, vitamins, & supplements you are currently taking *

Name, Dosage/Frequency, Duration, and Reason

Please list any allergies you have (seasonal, food, etc)

Do you have any other past medical histories or problems (i.e. illness, trauma, emotional distress, addictions, etc) or anything else that will help me clearly understand your current health status? Please explain *

General Stress Level *

None

Unmanageable

How would you describe your emotional health? *

Describe your current sleep routine (Mark all that apply) *

Sleep soundly

Not enough sleep

Difficulty falling asleep

Difficulty staying asleep

Sleep too heavy

Frequent nightmares

Required

How do you generally feel when you wake? *

How much water do you drink per day? *

Is the majority of your day spent: *

Sitting

Standing

Walking

Other:

Do you exercise? How many times per week? *

Yes

1-3 x week

4-7 x week

Other:

Required

FOR WOMEN: Do you have pain or cramping during menstruation?

Yes

Before Period

During Period

After Period

Other:

Are you or your partner currently pregnant and/or breastfeeding?

Yes

Other:

Clear selection

Are you trying to conceive?

Yes

Other:

Clear selection

FOR MEN: Do you have any prostate/erectile dysfunction/premature ejaculation complaints?

Yes

Other:

Clear selection

FOR ALL: What is today's appointment for? *

How long have you had this issue? *

What aggravates your issue? *

Does anything give you relief from this issue? *

Do you have an aversion to any particular scent?

Have you ever used any Holistic remedies before? (Mark all that apply) *

Yes

Aromatherapy

Herbal Remedies

Flower Essences

Homeopathy

Other:

Required

Who may we thank for referring you?

Mountain Sage Wellness Shop, LLC Informed Consent Form

I understand that this consultation is designed to gather information in order for Clinical Aromatherapist, Aimee Williams, to be able to create a customized holistic protocol that best supports my individual needs and goals that support my health & well-being.

I understand that Aimee Williams is not a medical doctor, therefore, will not diagnose me for illness, disease or any other physical or mental condition.

I understand the primary function of herbal and aromatic remedies is to enhance my overall well-being and to work in correlation with any current treatments that I am currently using. I understand that these customized products are not a substitute for medical treatments, and it is recommended that I consult with a qualified health professional for any physical or mental condition that I may have.

I understand that Aimee Williams neither claims, nor implies that any instruction, advice, counsel, recommendations, services, or products she or her representatives provide, whether in person or by internet or telephone, will cure, treat, prevent, or mitigate any disease condition; but are provided solely for the purpose of supporting the natural function of the body systems, and to improve general health & well-being.

I understand that I am financially responsible for this Personalized Wellness Consultation at the time of my appointment and that if I fail to arrive at the appointed time or miss an appointment, I am still responsible for the full amount of service.

I affirm that I have completed this health intake form accurately and honestly, and agree to notify Aimee Williams of any changes that may affect my health profile. I understand that all of my information is strictly confidential and if I wish for Aimee Williams to discuss my case with another practitioner that I request so in writing.

By signing this form, I give consent to a Personalized Wellness Consultation with Aimee Williams, CCA of Mountain Sage Wellness Shop, LLC. I acknowledge that I have read and understood the information provided in this form.

Client Signature *

Today's Date *

YYYY

Herbal and Aromatic remedies are not a substitute for medical care. If you are experiencing any specific medical problems & have not seen your medical doctor, I recommend that you do so immediately.

Send me a copy of my responses.

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