Personal Health Story | Oneness Wellness Lifestyles

Your Current Care

Share what support you are already receiving so we may honor the full picture of your care.

Date of Last Medical Exam

Currently Under a Doctor's Care?

Yes No

Doctor's Name

What are you being treated for?

Currently Taking Medications?

Yes No

Prescription Medications (Rx)

Non-Prescription / Over-the-Counter

Other Healers, Helpers, or Therapies?

Yes No

Who and/or what therapy? How long?

Your Focus & Intentions

What is calling you toward healing? Let your deepest knowing speak here.

What is your chief concern? *

What are your goals for health and life? (Body, mind, spirit, family, finance, community)

List any current symptoms, problems, or challenges

What are the three factors in your life most important to your daily health and well-being?

Review of Body Systems

Your body speaks its own language. Click the dots to indicate frequency: one dot for occasional, two for often, three for regular difficulty.

Not present 1 = Occasional 2 = Often 3 = Regular

Number of bowel movements daily

Your Past Story

Your history is part of your healing path. Share what your body has carried.

Do you have allergies?

Have you taken medications regularly (prescribed or OTC)?

Vitamin, mineral, or herbal supplements?

Any past operations or surgeries?

Any major accidents or injuries?

Any major illnesses or hospitalizations?

Tobacco use — current or history?

Current Past Never

Consent & Sacred Agreement

Before we sit together, please read and affirm your understanding.

As a client or member of Oneness Wellness Lifestyles (OWL) and/or Oneness by Shifa (OS!), you give consent to receive self-healing care remedies and information, and give permission and authority to practitioners, healers, therapists and caregivers to assist you in your self-healing with natural wellness protocols.

The suggested remedies and processes offered are usually beneficial when used correctly and seldom cause any problem. OWL/OS! practitioners will not provide care if we are aware that such care may be contraindicated. Conditions not disclosed in this health history intake form that would otherwise not be known render OWL/OS! indemnified and held harmless.

When actions are deemed non-compliant or contrary to self-healing protocols consented to in this agreement, OWL/OS! accepts no liability and remains indemnified and held harmless.

How did you hear about Shifa and Oneness Wellness?

If referred, by whom? (so we can thank them)

Your Electronic Signature *

Sign with your mouse or finger below

Print Name *

Date

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Your Story Has Been Received

Thank you for honoring your truth. Your Personal Health Story has been safely received and saved to your wellness record.

Your next step on this journey is to schedule your intake session with Shifa. This is where we sit together and honor the story you've shared.

Schedule Your Session with Shifa

You will also receive an email and text with this link for your convenience.

Oneness Wellness Lifestyles
[email protected]
808-207-7370

Your Data Has Been Captured

The direct connection to GoHighLevel encountered a pause. Your health story data is preserved below. You can copy it or download it for manual import.