Client Intake Form
Date of Birth
Place and Time of Birth
Person/Pets You Are Living With
What is the best way to reach you?
How would you rate your present state of health?
What brings you to Be Wild Woman?
Do you have specific health concerns?
Please list any current injury/illness/surgery hospitalization.
Please list any past injury/illness/surgery/trauma/ hospitalization/ accidents.
Is there any history of overwhelm, trauma, mental/emotional distress, or addiction in your family? This can include accidents, depression, loss,war, natural disasters, separations.
Were there any pregnancy or birth challenges with your birth that you know of? Was there any early trauma, upset or upheaval in the family such as accidents, natural disaster, loss of family member, move?
Are you currently under a doctor’s care? YES or NO.
Please list any conventional or alternative health care practitioners you go to and what you see them for.
Please list any medications, supplements you are currently taking.
Do you have a health or fitness program or practices?
If so please list what you do and frequency.
Are you happy with it?
Briefly describe your spiritual or religious beliefs or the basic ethical guidelines that inform your life.
(For Women) Do you menstruate?
When was your last menstrual period?
Age of first period
How frequently do you have your period?
If irregular, describe frequency
Is your flow heavy?
Spotting (Liners are fine)
Very Light Flow (Up to 2 regular pads/tampons a day)
Light Flow (Up to 3 regular pads/tampons a day)
Medium Flow (Up to 8 regular pads/tampons a day)
Heavy Flow (Up to 8 Large pads/tampons a day)
Super Heavy Flow (Up to 12 Large pads/tampons a day)
Varies (Light to Heavy)
Varies (Heavy to Light)
None of the selection
If none of the selection, please briefly describe:
How many days do you bleed?
Do you stain/bleed between periods?
Most of the time
Do you have pain, discomfort or concerns with your periods?
Check if (you are feeling):
If your periods have stopped do you have any symptoms associated with menopause?
Is there anything you'd like to share about your cycle?
Are you pregnant?
Have you had any pregnancies? If yes please note below number of:
If Live births, list any pregnancy, birth or post-partum challenges, complications or concerns.
List any other reproductive concerns/ menstrual/menopausal symptoms.
Are you experiencing any discomfort or pain now or on a regular basis in your body?
If yes, where and how do you experience it?
On a scale of 1-10, where would you place it?
How is your digestion? Do you have regular movements?
Describe your diet, how often, what you eat.
Are you happy with your diet?
Describe your relationship with your body.
What is your relationship with nature and the earth? Do you like or spend any time engaged with or in nature?
Where do you carry tension?
What helps you when you are stressed?
Have you ever experienced energy work, holistic health counseling, reflexology, chakra healing, or yoga before?
What do you love about your life?
What do you desire to experience?
What are your healing goals?
What would you like to let go of, shift and or gain from working with me?
How did you hear about Be Wild Woman?
Is there anything else you would like me to know?
I hereby understand that Kiana Love is an integrative healer & founder of Be Wild Woman. She is certified as an IET Master Instructor, Reiki Master, Sacred Centers Chakra Healer & Teacher, Core Vinyasa Flow Yoga, Holistic Health Counselor, Body-Mind Coach, Interfaith Minister & Reflexologist. She is not a medical doctor. As a health professional and educator, she is knowledgeable about health, the body and body symptoms, yet does not diagnose or prescribe. As a client of Kiana Love it is my responsibility to consult my physician about any and all medical concerns. She encourages you to keep your health team informed of your medical and health conditions & choices so we can work together to best serve you.