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The Womb Room Client Intake Form
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Client Intake Form
CONFIDENTIALITY AGREEMENT / HIPAA
I understand that my Womb Sauna Practitioner, SciHonor has received HIPAA training and will make every reasonable effort to maintain my privacy coinciding with HIPAA regulations intended for client and patient confidentiality
I give my permission for her, to take notes about me, including personal information that I choose to disclose to her regarding my physical, emotional state and personal history. I understand that it is important that SciHonor has accurate and complete medical history on current and all previous ailments that I may have or have had experienced; I will provide that information to her. I also understand that this information may anonymously be used for data collection, statistical purposes, and peer review and that she may use this information to provide me with a summary of my session for my own personal use and for the development of my regimen(s). I understand and acknowledge this and hereby consent to such use of my personal and medical information.
I understand that the statements and services offered have not been evaluated by the US Food and Drug Administration. This service is not intended to diagnose, treat, cure or prevent any disease. Those seeking treatment for a specific dis-ease should consult a qualified integrative physician, preferably a holistic physician, prior to using our service.
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Indicates required field
Full Legal Name
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First
Last
Preferred Name
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First
Last
Age
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Date of Birth (mm/dd/yyyy)
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Address
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Line 1
Line 2
City
State
Zip Code
Country
What is the best method of contact between sessions?
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Phone
Email
Text Message
FaceBook
Work
Phone Number
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Email
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FaceBook User Name
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Website
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Can we add you to our email distrobution list?
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Yes
No
Do we have your approval to discuss your session information with you via e-mail if necessary?
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Yes
No
Marital Status
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Married
Single
Divorced
Widowed
Other
Orientation
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Straight
Lesbian
Bisexual
Orientation; History of Any? If so, please explain
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Religious / Cultural Affiliation
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Emergency Contact
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First
Last
Emergency Contact Phone Number
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Emergency Contact Address
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Line 1
Line 2
City
State
Zip Code
Country
Emergency Contact Email
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What's Your Womb Story?
Has Your Womb experienced any kind of physical trauma? (Check all that apply)
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Sexual Abuse
Rape
Surgery (Including Cesarean Sections or Cervical Procedures)
Severe Impact or Force
Injuries
Other
Other? Please explain
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When did these incidents occur?
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Do you have a regular menses? * If yes, how often and for how many days? (i.e. every 28 days for 4 days max)
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Do you currently have, or have had in the past, the following: (Check all that apply)
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None
Fibroids
Ovarian Cysts
Polycystic Ovarian Syndrome (PCOS)
Tumors
Endometriosis
Amenorrhea
Hormone Imbalances
Adrenal Fatigue
PMS
Menopuase
Irregular Menses
Painful Menses
Clotting During Menses
Menses longer than 4 days
Infertility
Feminine Odor
Vaginal Discharge
Genital Itching
Sexually Transmitted Dis-eases
Miscarriages
Pregnancy
Abortions
Death of a Child
Rape/Incest
Use of Birth Control
Spotting in Between Periods
Other
What type of Sanitary products do you use during your menses?
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Standard Maxi Pads
Standard Tampons
Cloth/Reusable Maxi Pads
Pads Free of Dioxin, Fragrance, Pesticide, etc.
Organic Tampons Free of Dioxin, Fragrance, Pesticide, etc.
Cherish Premium Sanitary Napkins
What are your other health concerns? (Please list in order of severity)
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Please list dis-eases prevalent on both your maternal and paternal sides of your family: (i.e. diabetes, high blood pressure, cancers) and tell whether they are on the maternal or paternal side.
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Who is your Primary Care Physician?
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First
Last
Phone Number
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Who is your Midwife / Gynecologist?
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First
Last
Phone Number
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Address
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Line 1
Line 2
City
State
Zip Code
Country
What medications (prescribed or over the counter), herbs, vitamins, supplements, etc. are you currently taking? * (Also list what you are taking them for?)
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Medication & Supplements
Do you have any known contagious dis-eases at this time?
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Yes
No
Other
If yes, please explain
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If other, please explain
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Do you have a history or currently have any STD’s?
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Yes
No
Other
If YES, please explain
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Please list any areas where you experience pain or discomfort on your body?
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Do you have a medical diagnosis of any mental, personality, or social disorders? * (i.e. Obsessive Compulsive Disorder, Depression, Anxiety Disorder, Hoarding, and Schizophrenia)
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Yes
No
Other
If yes, please explain
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If Other, please explain
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How many hours of sleep do you get each night?
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How much water do you drink in one day?
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How many hours a week do you exercise?
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What Kinds?
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Do you have any allergies to any foods, environmental substances, medications, herbs, etc?
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Yes
No
If yes, please explain
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WOMB SAUNA LIABILITY POLICY
Here are recommendations for all clients of the Womb Sauna. The use of drugs, medication or alcohol prior to or during the sauna session may lead to dizziness or unconsciousness. Please consult your physician if you are in doubt of your ability to use the Womb Sauna for health reasons. Please discontinue the use of the sauna if you feel light-headed, dizzy or heat exhausted. Womb Sauna sessions should be limited to a maximum of 60 minutes. It is advisable to drink plenty of water before and after sauna session. It is advised not to eat at least one to two hours prior to your sauna session to avoid any ill feelings. Clients using any medications must consult a physician or pharmacist prior to the use of the sauna. Pregnant women should consult their physician prior to the use of the sauna. Excessive body temperatures have a potential for causing fetal damage during the early days of pregnancy. Do not use any chemicals or lotions prior to your sauna session. These items may block pores and affect perspiration as well as stain the wood. By checking the agreement box below, I acknowledge and accept the risks inherent in the use of the Womb Sauna. I voluntarily assume the risk of injury, accident or death, which may arise from the use of the Womb Sauna. I and any of my heirs, executors, representatives or assigns hereby release from all claims or liabilities for personal injury or property damages of any kind sustained while in the Womb Sauna, during the use of the Womb Sauna and from any advice provided by an employee, independent contractor or any representative. I agree that this intake form and Waiver is in effect for all Womb Sauna sessions and will not expire unless requested by either party.
By checking the box below you hereby agree to the above terms *
I agree to the terms
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Yes
WELCOME
My commitment to you as your Womb Sauna Practitioner is to journey with you towards healing yourself and empowering yourself as a woman through a mind, body, spirit approach.
*Your name and contact information will never be shared, unless you give us permission to do so for various reasons.
Please check & sign here to give us permission to share your name & contact information.
Please check
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I give my Womb Sauna Practitioner permissionto share my name and contact information
How did you discover the Womb Sauna? (Check all that apply)
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Internet Search Engine (Yahoo, Google)
Facebook
Twitter
Referral
Instagram
Other
Today you are one step closer to a new you.
Feel empowered because you are on a positive path to growth and well-being.
What are you willing to manifest?...
If you have not yet done so, please call 973-9-DOULAS to make an appointment to begin your transformation and healing.
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