Mindhance Wellness Intake
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Mindhance Wellness
 
 
Information
Today’s Date:
 
Name:
  
Date of Birth:
  
Address:
  
Phone home and cell:
  
E-mail:
  
 
 

Health Concerns
Priority Concern Onset Month/year How often * Severity**
1
        
2
        
3
        
4
        
 
 
What are your goals for this visit?
1.
  
2.
  
3.
  
 
 
Do you have any allergies to medications, foods, pollens, etc.?
Allergen/Triggers (medication, food, etc.) Reaction
   
   
   
   
 
 
Do you have any disabilities? ‚ No ‚ Yes (Describe):
           
Previous Diagnosis? ‚ No ‚ Yes (Describe):
 
 
List any prescription medications you are taking:
Medication
Reason for taking
Dose/Times per day
Year started
Side Effects
         
         
         
         
         
         
 
 
Do you cut back or not take any medications because of costs or side effects? ‚ No ‚ Yes
 
 
List any over the counter medications you are taking:
Medication
Reason for taking
Dose/Times per day
Year started
Side Effects
         
         
         
         
         
 
 
List any herbs, supplements or vitamins you are taking: (Give Brand)
Supplement
Reason for taking
Dose/Times per day
Year started
Side Effects
         
         
         
         
         
         
         
 
 
Rate your overall discomfort with your medication
      1   2   3   4   5   6   7   8   9   10  
 
 
        Best Worst
 
 
How would you rate your stress level in the past month?
      1   2   3   4   5   6   7   8   9   10  
 
 
        Completely relaxed Extremely stressed
 
 
Name three things you know you should be doing for your health but are not currently doing.
1.
 ______________________________________________________________________________
2.
 ______________________________________________________________________________
3.
 ______________________________________________________________________________
 
 

How would you rate your emotional state in the past month?
      1   2   3   4   5   6   7   8   9   10  
        Sad/depressed Happy/calm
 

      Please answer the following:
 
Over the past two weeks, how often have you:
None or little of the time
Some of the time
Most of the time
All of the time
1 been feeling low in energy, slowed down?        
2 been blaming yourself for things?        
3 had poor appetite?        
4 had difficulty falling asleep, staying asleep?        
5 been feeling hopeless about the future?        
6 been feeling blue?        
7 been feeling no interest in things?        
8 had feelings of worthlessness?        
9 thought about or wanted to commit suicide?        
10 had difficulty concentrating or making decisions?        
 
  Is there anything else about your health you think I should know?

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  TREATMENT AND CONFIDENTIALITY  
 
In signing the form below, I hereby voluntarily consent to have treatment. I understand I can terminate this relationship at anytime. I also understand that this service not considered mental health counseling but is about my body and mind and spiritual path. I am aware this service is confidential and the information discussed cannot be disclosed without my consent. Tyler Woods Ph.D. may consult with other practitioners and professionals to provide the best possible care however, no names or identifying features will be disclosed. I understand that I take full responsibility for any vitamin or herb recommended and the outcome of such treatment and understand fully that the practitioner is strictly giving me guidelines as to what alternatives to use. I understand fully that Tyler Woods is not a licensed counselor but a licensed holistic health practitioner that specializes in holistic mental health, grief coaching and psychospirituality.
 
  ______________________________
Name		 ______________________________
Date		  
 
My desire to take an alternative approach to my mental and physical health issues are based on my decisions and my decisions alone. By signing this statement I agree that I am solely responsible for the outcome of my treatment.
 
  ______________________________
Name		 ______________________________
Date