Intake Form for wildernessFusion Clients

Name

First Name

Last Name

Phone

(###)

###

####

Address

Date & Place of Birth

What kind of heart condition do you have?

How does this effect your daily life?

Your physical body? Your relationships?

In addition to dealing with this heart condition, are there other health issues we should be aware of?

How is your stress level?

What are your top stressors?

How do you experience stress?

In your physical body? In your mind? Emotionally?

What is your relationship with rhythm?

Day to day... Seasonal... How you work... How you play...

What are you seeking by coming to this healing clinic?

Are there any other life circumstances you would like us to be aware of?

Are you on any medications or supplements?

If so, please list: