Intake

GENERAL PATIENT INTAKE
INFORMATION FOR CARE AT COCOONING®
requested by Cosima Lux

Please fill out the from below as much as possible. We can always discuss these fields in more detail. The information provided helps me prepare for our session and is 100% confidential. Please make sure to hit "Submit" at the bottom of the form.

Name(Required)

First Last

Birth Date(Required)

Marital Status

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How did you learn of Cocooning® Integrative Health or Cosima Lux?(Required)

Occupation:

Ethnicity and Maternal language:

Pronouns:

Leaning needs/ how learn best:

Please Note:The start of this intake is focused on physical questions and the emotional intake is later – please note any and all issues even if they are not your primary reason for consultation to best provide a holistic view of you as a person.

Skip questions that are not applicable, or ask me if questions are unclear or need further discussion. You are never limited to a specific length response.

You may choose not to answer any question. You may also write – prefer to discuss in person as (PDP) Your answers will be saved and I will not be able to edit these, but we can also continue to add provider notes after your responses, as we work together.

I will not address everything on this intake with you but it will be included in creating your personalized therapeutic plan.

It’s long, I know, but hang in there… and Welcome to integrative healthcare, where all your information is important!

SITUATION AND EXPECTATIONS

Please describe generally the health problems that you are having now in your own words and prioritize them by concern or intensity of issue. (you will have a chance to further describe specific symptoms)

What is the main intention of your sessions? What are your hopes and goals in working together?

How much time can you dedicate to these issues: At home? In sessions?

YOUR PERSPECTIVE

What do you think caused / is causing this problem?

What do you think will help you?

How do you hope I will help this problem?

What are you currently doing to deal with this challenge?

Do you have any current diseases/illness or diagnoses?

Do you have imaging/labs/or other diagnostics in your possession?

Are you under treatment?

Yes

If so, who is your provider?

(note that no information may be shared without your written consent)

What is your provider's phone number?

Who else have you consulted for this problem? (spiritual advisor, trainer, massage therapist etc)

What have they suggested?

SYMPTOM EVALUATION

What is the location of your discomfort/concern? (Whether or not physical – please describe location if able)

Please describe your symptoms:

When did your symptom(s) begin? (date and if significant event, when in relation to)

If not answered above:

Was there a specific incident prior to the onset of your symptoms and/or is this a chronic condition/concern?

What time(s) of day/night do the symptoms present?

Did your symptoms begin suddenly or gradually?

Suddenly

Gradually

Is the symptom constant or intermittent?

Constant

Intermittent

How long does the symptom(s) last?

How often do you experience this difficulty?

What makes your symptoms worse? ( i.e. stress, movement, rest, sitting, crowds, time of day, certain foods, sounds, weather etc.?)

What makes your symptoms better? (i.e. mindfulness practice, darkness, movement, eating, bathing, foods, socializing, supplements or medication, etc.)

How have the symptom(s) changed since they began?

Yes

If so – what changed in your life at that time?

(How) do your symptoms impact your quality of life?

Do your symptoms have an impact on your participation in your daily activities; i.e. work, leisure, exercise, etc.?

Are there specific daily activities that you are not able to do because of your symptoms that you would like to be able to resume?

Do your symptoms interfere with your sleep?

Yes

SPECIFIC PAIN EVALUATION

Are you experiencing pain now?

Yes

When in the 24 day is your pain at its worst?

When is it at it’s lowest?

How would you describe your pain? (emotional, physical, dull, sharp, piercing, electric, constant, intermittent, suffocating, located in the same place, pain moves around, etc)

On a scale of 1-10 (1= least pain, 10= most pain), rate the intensity of your pain.

Please enter a number from 1 to 10.

Do you have inflammation that you know of?

Yes

If yes: What part of your body has inflammation?

How would you describe your inflammatory symptoms (red, swollen, warm, hot, tight, etc.?)

What body positions help alleviate the pain and or inflammation?

What is the most comfortable position for you generally?

How does movement affect the pain?

Have you noticed if other factors affect the pain? (weather, stress, mood, lack of sleep…)

SELF CARE

How have you attempted to manage this problem or your symptoms?

Would you say you self medicate – if so how?

How do you generally care for yourself to maintain your physical and emotional health?

PHARMACEUTICAL CARE

Do you currently take any medication for this or other issues? If yes, what, dosage and as of when?

Are you taking any supplements? If so what and how often/dosage?

LIFESTYLE QUESTIONS

Weight:

Height:

Gender as you’d describe it:

This next section pertains only to people with/or having had vaginas. Otherwise please skip

Age of onset of menses

Last menstrual cycle

Duration of cycle

Pain with periods:

where, when, quality?

Pain outside of periods:

where, when, quality?

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What do you do for this pain?

What makes it better or worse?

Please describe typical flow pattern?

What changes with your cycle and when?

Eg mood, appetite, sleep, skin

Are you pregnant, if so how far along?

What number pregnancy is this?

Are you trying to get pregnant?

For how long? What are the outcomes to date?

Have you been pregnant in the past?

If so, for each pregnancy what were the outcomes?

Eg: Did you carry to term, vaginal or C/S birth, deliver pre or post dates, abort, miscarry, stillbirth, other?

Were there complications at your birth?

Do you have symptoms of Peri/menopause?

If so, what? Starting when?

Are any menopausal or menstrual symptoms interfering with your day today life? How?

Are you taking any hormonal supplementation?

Please specify what, why, and for how long?

Have you been given any gynecologic or reproductive diagnoses? What are they?

Continued general questionnaire

Is there anything not noted that I should know about your sexual or reproductive health?

What time do you go to sleep?

How many hours sleep do you generally sleep?

How do you sleep?

How do you feel after waking?

What time to you wake up? (in the morning, during the night)

Are you satisfied with your sleep habits?

Do you have issues with libido?

Describe current health / fitness practices

How is your appetite? (weak, intermittent, strong, burning, steady)

When are you hungry?

When do you eat?

Do you have dietary limitations or restrictions or allergies?

How do you feel after eating? (bloated, heavy, gassy, heartburn, painful, tired, energized)

How is your elimination?

How frequent are you eliminating?

How is your urination?

Do you experience any skin problems? (Acne, dryness, eczema, hives, rashes)

What are your body sensations? (eg: hot/cold face/hands/feet, chest tightness, stomach tightness, heart palpitations, etc)

How often do these symptoms occur?

Do you sweat?

profusely

only during exercise

almost never

Do you work? If so what does your job(s) consist of?

How many hours a week do you work? Are you sedentary, active, or straining when at work? Please describe

Do you get headaches?

Frequently

Occasionally

Never

How many headaches in a one month period?

When you do get sick is it generally - head cold, chest cold, digestive, other?

How much water do you drink? (how many 8 oz glasses per day)

And how do you drink? – with meals, a lot at one time, sipping all day, etc

What is your general sugar intake?

Do you use tobacco? If so how much and how often?

Are you open to making dietary changes if they may help to alleviate your symptoms?

Do you have pets or animals in your life? If so, tell me about your interactions with them: eg: horses – do you ride/groom them, dogs – what breed/do you walk on leash, injured or old pet you are caring for? etc.

Any pets you have allergies to – how do symptoms present?

Do you have children (ages, gender, special needs, other)?

Are you a caretaker for anyone else? Who? What is your role?

Are you religious and or spiritual?

If so, how does this manifest in your life?

And do you have religious guides currently?

CLIENT MEDICAL HISTORY

Have you had any major injuries, or acute illnesses? If so what and when?

What was the treatment?

Any surgical history?

Do you have a family history of this kind of condition or symptom?

Yes

Unknown

Family history of other conditions that you do not have present?

What is your stress level from 1-10 (one being no stress, 10 being overwhelming)

Please enter a number from 1 to 10.

What is causing your stress?

Is this different from the norm for you? If so – when did this change?

When dealing with stress what is your normal reaction (anger, fear, inertia)

Do you have any mental health diagnoses not mentioned above?

Have you ever experienced trauma that you care to mention?

This could be surgical, medical, emotional or physical or sexual abuse, it could be oppression or discrimination, violence, or combat, or any other form of trauma that you feel has impacted you and that you may still be processing – as we often do.

Or do you have past significant trauma that you feel you have resolved?

Do you recall the events or trauma you mention?

Yes

Partially

Have you sought help for this and are you in any treatment now (therapeutic sessions or medications?)

Yes

If so what medications or treatment?

Are there triggers that you are aware of that you would like to avoid during our sessions? (words, sounds, music, etc)

Please mention if there are things that could improve our work together such as avoiding any form of assist or contact, breath work, needing to be in an open space, lighting, having someone else present, doing sessions virtually, etc…

We generally will not be talking about your trauma. But are there aspects of your trauma you would like to focus on, or conversely, not discuss or mention?

Are you aware of this or other traumas having taken hold of areas of your body (eg: car accident knee pain or headaches triggered when find self in closed spaces, panic attacks at sunset, etc)

Do you feel safe in the environment we will do our sessions in?

Do you feel safe in all your environments? If not please explain

Any recent or past significant life changes not mentioned above that you would like to share?

Is there anything else you’d like to tell me about what is going on in your life?

Do you have any transmissible diseases or conditions?

If yes, please describe

If there is anything in this document you have shared but do not wish to discuss with me further, at this time, please let me know here:

Lastly, what brings you joy? Tell me about that…

Thank you for taking the time to fully complete this in-take form.

Please note that as a mandatory reporter, I will keep sessions with minors and vulnerable adults confidential as well, outside of any information I receive related to suspected abuse.

Please know that your personal information will be kept confidential and stored with the utmost regard. I am honored to be entrusted with your care and look forward to working with you.

In health and kindness,
Cosima Lux

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