awakening | expression | healing | essence | well-being

mindset | desire | manifestation | transformation

Journey Medical Intake Form

The information you provide here displays your commitment to your journey, and we greatly appreciate the investment of your time, truth, and vulnerability.

As with all of the information shared in our community, your completed form is held strictly confidential and will not be sold or shared outside of your Journey guides in any way.

You will receive a copy of your form – save it as a reference for reflection before and after this and future Journeys. Observing and monitoring your growth enhances your transformation process.

Let's get started... Wrap your arms around your beautiful self, fill your lungs with self-love, and exhale out all your worries 🙌

First Name *

Last Name *

What name do you want to be called?

What are your preferred pronouns?

Email *

Phone *

Date of birth *

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Number *

Who Were You Referred By *

If you recently stopped taking any medical health prescribed or OTC medications related to any current conditions, please list the medications and note when you stopped taking them. Include natural supplements, herbal medicines, and vitamins. *

Please list any allergies you have to medication, natural supplements, herbal medicines, vitamins, etc. *

Cardiovascular Health

Cardiovascular health refers to the health of your heart and blood vessels. Share ALL details, risks, and concerns about your past and current cardiovascular health, such as low or high blood pressure, coronary heart disease, stroke, heart attack, arrhythmias, vein or value problems, palpitations, flutters, murmur, AFib, DFib, pulse-quickening or slowing, blockage or risk of blockage, etc. Include all related medications, surgeries, risks, or concerns about your cardiovascular health.

Please share all past and current details of your cardiovascular health. Include all related medications, surgeries, risks, or concerns about your past and current cardiovascular health *

Plant Medicine

Are you currently or planning to get pregnant? *

Yes

Have you ever taken sacred plant medicines? *

Yes

If you answered yes, please provide the details of your experiences with plant medicines (dates, locations, experience, etc.). Please share your feelings about trying plant medicines if you answered no. *

Please describe your current living and work environment that you will be returning to after our time together. This information is important in helping prepare you for returning to your home and work life. *

Please share your intention for wanting to participate in sacred plant medicine. Take time to reflect on this question. It is very important for us (and you) to clarify what you hope to achieve. *

Drugs & Alcohol

If you have ever been diagnosed, treated, or self-identified with an alcohol use disorder, list the details of your experience, including the date (s) or time span of your addiction and whether you have undergone any therapy or rehabilitation to heal. *

If you have ever been diagnosed, treated, or self-identified with a drug addiction, list the details of your experience, including the date (s) or time span of your addiction and whether you have undergone any therapy or rehabilitation to heal. *

If you have ever experienced addiction to any other substances or activities (work, sex, food, gambling) either in the past or present, list the details of your experience, including the date (s) or time span of your addiction and whether you have undergone any therapy or rehabilitation to heal. *

Food & Diet

Please list any food allergies and the reaction that results if you ingest the food. *

Please list any severe or potentially life-threatening allergies that would require the use of an Epi-Pen. *

What is your typical dietary preference? *

Omnivore (I eat red meat and fish) Pescetarian (I only eat fish as a meat source)

Vegetarian (I do not eat meat or fish; I will eat eggs, milk and cheese)

Vegan (strictly no animal products)

Gluten-free

Dairy-free