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Experience Healing with
Indigenous Healing Studio
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Medical Screening Form
Full Name
*
Date of Birth
*
Month
Month
Day
Year
Do you presently or have you ever suffered from any of the following?
*
Heart problems
High blood pressure
High cholesterol
Stroke
Lung issues
Cancer
Diabetes
Current broken bones/fractures
Arthritis
HIV/AIDS
Kidney problems
Repeated infections
Thyroid problems
Skin disease or sensitivity
Depression
Epilepsy/Seizures
Alergies
Have you had any surgeries or major dental work within that past year?
*
Do you smoke?
*
Yes
No
Do you drink?
*
Yes
No
Do you have a pacemaker?
*
Yes
No
Do you suffer from insomnia (disturbed sleep)?
*
Yes
No
Do you suffer from chronic migraines?
*
Yes
No
Do you have significant stress in your life?
*
Yes
No
(For women) Are you pregnant?
Yes
No
Are you sensitive to smoke, the burning of sage, cedar, Palo Santo, or spirit tobacco?
*
Yes
No
Do you prefer working with/without essential oils?
*
Please share any health or well-being concerns.
Signature
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Date
Month
Month
Day
Year
Submit
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