Health FormPlease fill out this basic health form. Name First Name Last Name Allergens (including medications, pollen, latex, venom, food ETC) * Please enter your allergens and detail out your reaction to them (i.e. bees - anaphylactic). If you have no allergies, simply write N/A Do you experience: ADHD/ADD Sensory Processing Difficulties Depression Suicide Attempts Fainting Spells (either due to a diagnosed condition or other) Anemia Low Blood Pressure High Blood Pressure Abnormal Heart Rate (please detail specifics below) Cancer (please detail specifics below) Thyroid Disease Renal Disease Other Heart Disease Epilepsy Addiction of any form (please detail specifics below) Asthma/COPD/Breathing Difficulties Autism PTSD/PTSI Anxiety including Panic Attacks Phobias (please detail specifics below) Degenerative Conditions (please details specifics down below) Digestive or Bowel Disease (please detail specifics down below) Medical Conditions (including checked medical conditions from the list above that require more detail) Please list any medical conditions, specifically ongoing, including asthma, surgeries, injuries, illnesses, disabilities etc Are you taking any medications? * This is important so I know which plants may not be safe for your consumption, due to potential medication interactions. If you're not taking anything, please write N/A Dietary Needs Please let me know if you have any dietary needs/restrictions. Do you understand and agree that I will be giving this health information to any emergency medical personnel, should they be called to treat you. * Yes, I understand and agree No, I do not understand/I do not agree Signature Please sign your name below consenting that everything you have listed is accurate to the best of your knowledge, that you are submitting this medical history of your own free will, and knowing that Sia Ray and Folk & Fire are not responsible for any injury, illness or death that comes from omitted health information. By signing you understand and agree that your e-signature is as legal and binding as a physically written signature Thank you!
