THE WOMB DETOX INTAKE FORM
PLEASE COMPLETE & SUBMIT THE FORM. Email thehealthydiva@gmail.com and say you have completed the form and you will get an email response with further instructions.
Name
Your answer
Address
Your answer
Phone
Your answer
Email
Your answer
Emergency Contact
Your answer
Relation
Your answer
Doctor or Specialist
Your answer
Contact
Your answer
Marital Status
Referred by
Your answer
Education
Occupation
Your answer
How long have you been there
Your answer
How many hours worked weekly
Your answer
List any previous illnesses including childhood illness or chronic viral infections, any surgeries, traumas or accidents, even if unrelated to your current condition.
Your answer
List any allergies and the reaction you have
Your answer
List any medications, vitamins, minerals or supplements you are taking
Your answer
Are there any conditions in your family’s medical history?
Your answer
What is the main condition for which you are seeking treatment?
Your answer
Does anyone else in your family have this or had this
If so how are/did they treat it?
Your answer
What is the history of this condition (ie. when and how did it start)?
Your answer
What makes it worse or better?
Your answer
What have you already tried for treatment?
Your answer
Do you vacation regularly?
When was your last vacation?
Do you leave town?
Do you relax on vacation catching up on activities for yourself?
Do you work through your vacation time cleaning house or doing chores?
Do you make time for yourself even if you have a family to look after?
Do you exercise?
What type?
Your answer
How many times weekly?
Your answer
How many years have you been doing this exercise?
Your answer
What level of stress do you have?
How do you handle stress?
What are the stressors in your life?
Your answer
How well do you adapt to change?
What do you do for self care, downtime or relaxing?
What food and drinks do you consume regularly?
Are you
List a typical day of food you consume. List the times, meal (e.g. breakfast, lunch, diner or snack and amounts eaten)..
Your answer
List any alternative treatments you are currently using or have used and the results.
Your answer
List any colon issues i.e.
(Females) Are your periods regular?
Are you currently trying to get pregnant?
Do you have or have you had?
Required
List any other health information that may be useful to assisting with this condition, (be as clear as possible) List any conditions you have been treated for in the past or medications you have been on.
Your answer
DISCLAIMER: The statements and services offered have not been evaluated by Health Canada. 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. The information, classes, services or treatments received by me from THE WOMB DETOX are not to replace the treatment or advice of a physician. The information and classes from THE WOMB DETOX are for educational purposes. I understand THE WOMB DETOX will not be held liable for any aspects of treatments, classes or programs I undertake with THE WOMB DETOX.
Required
LIABILITY POLICY: Recommendations for all clients of the Vaginal Steam Treatment. The use of drugs, medication or alcohol prior to or during the session may lead to dizziness or unconsciousness. Please consult your physician if you are in doubt of your ability to use vaginal steam treatment for health reasons. Please discontinue the use of the treatment if you feel light-headed, dizzy or heat exhausted. Vaginal steam sessions are limited to 90 minutes. It is advisable to drink plenty of water or minerals before and after sauna session. It is advised not to eat at least one to two hours prior to your session. Clients using any medication must consult a physician or pharmacist prior to treatment. Pregnant women should consult their physician prior to treatment. 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 box and signing below, I acknowledge and accept the risks inherent in the use of the Vaginal Steam Treatment. I voluntarily assume the risk of injury, accident or death, which may arise from the use of the Vaginal Steam Treatment. THE WOMB DETOX and any of their 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 Vaginal Steam Treatment, during the use of the treatment 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 Vaginal Steam Treatment sessions or other Womb Detox treatments and will not expire unless requested by either party.
Required
List times and dates you are AVAILABLE for treatments. THIS IS NOT A SCHEDULED APPOINTMENT IT IS JUST A TIME AND DATE TO GET YOUR APPOINTMENT MATCHED UP WITH WHAT IS AVAILABLE.
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CANCELLATION POLICY: I understand that I will be charged a cancellation fee for late or no cancelation notification of less than 24hrs for a scheduled appointment and will adhere to any policies. BY SUBMITTING THIS FORM I AGREE TO THE TERMS AND CONDITIONS SET BY THE WOMB DETOX.
Required
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