Full Legal Name (First, MI, Last)

Preferred/Nick Name:

Name of Parent/Guardian (if under 18yo) (First, MI, Last)

Primary/Main Phone #:

Secondary Phone:

Address (House Number, Street, City, State, Zip):

Emergency Contact (Name and Number):

Email Address:

How did you hear about us/Referred by?

If referred/recommended by a person, please let us know who we can thank:

Age & Date of Birth: 

* We do not ask weight because we do not feel that is an accurate measurement of health.

Better measurements of progress are:

How you feel as you move your body in new and challenging ways!

Activities you get to participate in that you desire to be able to do (new or renew)!

**However, if you are interested in tracking definition changes, we suggest you take measurements of your waist, hips, upper thighs, and upper arms. You are welcome to share your baseline measurements here if you would like to.

Height: ____ feet ____inches

How would you rate your current physical health? 1 (poor) through 5 (excellent): ___

How would you rate your mental/emotional health? 1 (poor) through 5 (excellent): ___

How would you rate your spiritual health? 1 (poor) through 5 (excellent)

How would you rate your general overall health:  1 (poor) through 5 (excellent)

Any additional health history information you wish to share or explain from above in more detail?

List allergies, sensory/food intolerances, strong dislikes (of anything that comes to mind that might prevent you from participating if asked to partake in them - please indicate if you would like to avoid these altogether or help you work through them):

History of Injuries - Sports or otherwise (location on body and year occured):

Surgical/Hospitalization History (describe location on body, for what, and year): Ex: Left knee meniscus tear repair 2005

Any traumatic events or triggers you can recall that may influence your care that you wish to share?

Activity Restrictions (per self or per healthcare provider):

What would you like to accomplish in your time working with WH&C?

Are you open to making lifestyle changes that include better nutrition and movements based on DNA results, along with evidence-based, therapeutic, functional solutions that may be unconventional and non-mainstream?

• Do you prefer to SKIP ALL further questions, and schedule an extra session to discuss 1:1 

I am testifying by typing my full name below with today's date that all the information on this form is accurate and true to the best of my knowledge. I understand that I am responsible for updating my information with my coach and other health professionals with whom I am working for the best continuum of care and health outcomes.

Marital Status:

List family members or friends living with you and their ages:

Any Personal History that may be pertinent to your care (Mental, Physical, and Spiritual Health):

Explain below any further personal or family history that may be pertinent to your care (Mental, Physical, and Spiritual Health) :

Please list your top 3 concerns you are currently dealing with and how they affect your physical, mental, emotional, relational, and/or spiritual health with symptoms, onset, and how it has changed over the past year? 

How are the above factors impacting your life?

What other healthcare providers, specialists, and/or therapies are you seeing or have you seen in the past?

List ANY and ALL medications, patches, supplements you are taking or have taken in the last 3 months and reason you are taking them:

What are your goals/expectations for working with Wild Haven & Co health and wellbeing practitioners?

Rate your current pain 0-10 (0=no pain; 10= emergency room)? 

Best or lowest pain rating you’ve experienced with this current concern?

Worst pain rating you’ve experienced with this current concern?

Describe locations of pain or symptoms within or on your body?

What activities, positions, etc aggravate your symptoms?

What relieves your symptoms?

When do you feel your best during the day or even certain days of the week that you notice you feel better? Your Worst? and What do you believe are the reasons?

Morning:

Afternoon:

Evening:

Night:

Days of the week:

Rate your current perceived sleep quality from 0-10 (0= very poor, very dissatisfied; 10 = very satisfied, no problems)

How much sleep on average do you get per 24 hours?

List the typical reasons for sleep disturbances if you have them:

List any perceived food relationship difficulties (such as appetite control, eating patterns, etc): 

What are your daily bowel habits?

How many bowel movements do you have each day?

Level of Activity Currently:

Over the past 2 weeks, how often have you been bothered by little interest or pleasure in doing things?

Over the past 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?

Rate your current level of stress from 0-10 (0=none, 10 = as bad as it can be): 

What are you currently doing for your wellbeing and your health (self/soul care)?

Describe your typical or preferred type(s) of wellness and physical activity/exercises?

What do you feel you need for your symptoms to improve?

Future Life Perspective: What do you foresee in your future for your mental/emotional health if nothing changes?

What do you foresee in your future for your mental/emotional health if things change for the better?

By filling out my Full Name Below, I acknowledge that I have disclosed all of my health history to the best of my ability and knowledge. I understand that full disclosure is in my best interest in order to help my practitioner help me function well, make appropriate referrals, and provide the safest, most appropriate care. I will provide any updates to my health history to my practitioner in a reasonable time frame and will communicate any changes or concerns in conjunction with other healthcare providers for a more comprehensive, complementary care approach.