Sacred Waters Holistic Health Assessment

Holistic Health & Lifestyle Assessment
First Name*
Last Name*
Phone Number*
E-mail*
Mobile Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Birth Date*

MonthDayYear
Height*
Weight*
Approximate or Best Guest
What is your ideal weight or where do you feel the healthiest?*
Marital/Family Status*

SingleMarried/PartnerDivorcedWidowChildrenI am a minor
Children*

YesNo
Are you responsible for providing care for another member of your home, i.e. spouse, children, parent or other family member? If yes, provide brief detail.*
This helps to determine how to support certain lifestyle conditions.
Occupation/Industry*
Please specify. This helps to determine how to support certain lifestyle conditions.
Referred By - Name of Person if Applicable
Please specify Google, Yahoo, Facebook, t.v., radio, flyer, or advertisement if applicable.
Which service(s) are you interested in?*

Detox/Cleanse SupportLifestyle/Wellbeing SupportWeight Loss SupportColon Hydrotherapy/Colon CleanseGut Health SupportEnergetic Health AssessmentWorkshop/ClassesOther
What is your current health and wellness goal?*
General Health
How often do you have a bowel movement?

3 Daily2 Daily1 Daily1-3 WeeklyOther
Have you ever had professional Colon Hydrotherapy before?*

YesNo
If yes, specify approximate date:
Have you had a surgical procedure within the last year? Please reply YES or NO. If yes, please explain:*
Do you have any physical complaints or symptoms? Please reply YES or NO. If yes, please explain:*
Any diagnoses of chronic disease?*

YesNoOther
Do you take any medications daily? If yes, please list the conditions only:*
General Health Assessment

To help us understand what is most important to you about your health, please indicate which of these areas are of concern to you at this time.

Your Health Matters

	Very Concerned	Moderate Concern	Not Concerned
Weight
Stress
Anti-aging
Immune Health
Energy Sleep
Digestion/Gut Health
Hormonal Health
Allergies/Respiratory
Skin/Hair/Nails
Pain-relief
Strength/Flexibility

How do you rate the overall quality of your health?*

Excellent - Never sick, no complaintsGood - Sick once per year, only minor complaintsFair - Sick more than once a year, occasional symptomsPoor - Chronic symptoms, minor to major complaints.Managing a chronic illness with prescription or over the counter medication.
How do you rate the overall quality of your emotional/mental well-being?*

Excellent - Satisfied with personal choices and daily living.Good - Only minor complaints or changes desired.Fair - Occasional depression/frustration, irritability and/or stress.Poor - Chronic depression, major complaints.Managing chronic depression with prescription or over the counter medication.
What improvements would you like to make for your health and wellbeing?*
Are you open to learning more about holistic health or alternative medicine and how it may assist you in improving your health?*

YesUnsureNot interested in learning about holistic health.
Have you ever experienced a guided detox or cleanse with a natural health professional or holistic health coach?*

YesNo
General Health Ratings

Please rate the severity of the following symptoms/health concerns that currently apply to you on a scale of 0 to 5, with "0" showing no symptoms, no concern or not applicable and "5" being problematic or very concerned.

General Health - Current or recent past

	5	4	3	2	1	0
Acne
Allergies
Belching/Gas/Bloat
Blood in Urine
Boils
Bruise Easily
Chest Pain
Chills
Chronic Cough
Constipation
Depression
Diarrhea
Difficult Breathing
Difficult Digestion
Dry Skin
Erectile Dysfunction
Excessive Hunger
Fainting
Fatigue/Low Energy
Fevers
Fibroids/Cysts
Gall Bladder Trouble
Headaches/Migraines
Insomnia
Itching
Jaundice
Kidney Problems
Knee or joint pain
Liver Trouble
Libido/Sex Drive Low
Nausea
Nervousness/Anxiety
Overweight
Pain - General
Pain - Abdominal
Parasites
Poor Appetite
Sinus/Respiratory
Skin Eruptions/Rash
Stress
Sweats/Heavy Perspiration
Urinary (frequent or painful)
Yeast/Vaginal Infections

Lifestyle/Habits of Health
How do you rate your overall energy level on a daily basis?*

ExcellentGoodFairPoor
How many hours of sleep do you get nightly?*
Do you feel rested when you wake up?*

YesNo
Do you feel like you're under stress? If so, explain:*
How often do you exercise?*

DailyWeeklyOccasionallyNever
What type of exercise, if any?*
How much water do you drink daily?*
What type of water do you drink?*

TapBottleOtherNone
After drinking water, do you ever feel bloated*

YesNo
Dietary Habits

Some say you are what you eat. Please share candidly, there is no judgment here. Standard American Foods, include fast and processed foods. Whole and clean food items include fresh fruit and vegetables and naturally raised meats.
On average how healthy would you rate your meals?*

Whole and Clean Foods DailyWhole Foods Most Days, Needs ImprovementStandard American DietMy diet needs a full overhaul
Please share what is your favorite food and/or meal or share what you enjoy eating regardless of how often you eat it?*
How often do you eat your favorite food and/or meal?*
Do you have any food allergies? If yes, which foods?*
How many meals or how often do you eat in a day?*
How many days a week do you dine out?*

1-23-56-7None
How much do you or your household spend on dining out weekly?

$200 or more$100-$200$25-$100Less than $25
What if any, keeps you from cooking at home (check all that apply)?*

Lack of timeLack of energy or enthusiasmLack of cooking ability/meal ideasPrefer to eat outI already cook a lotOther
Please mark how often, if any you eat the items below:
Red Meat*

DailyWeekly ( 1 to 2 meals)OccasionallyNever
Seafood*

DailyWeekly (1 to 2 meals)OccasionallyNever
Chicken/Turkey*

DailyWeekly (1 to 2 meals)OccasionallyNever
Other meat*

DailyWeekly (1 to 2 meals)OccasionallyNever
Green Leafy-Uncooked Vegetables (including salads)*

DailyWeekly (1 to 2 meals)OccasionallyNever
Cooked Vegetables*

DailyWeekly (1 to 2 meals)OccasionallyNever
Fast or Processed Foods*

DailyWeekly (1 to 2 meals)OccasionallyNever
Fresh Fruit*

EverydayWeekly (3 or less servings)Never
Juicing/Smoothies*

DailyWeekly (1 to 2 meals)OccasionallyNever
How often is your intake of refined/processed sugar at 25 grams or more per day? (3 tbsp=14 g) Tip: The average 12 oz. soda contains about 40 grams of sugar.*

DailyWeekly (1 to 3 srvgs)Monthly (1 to 3 srvgs)Never
Do you follow a special diet? i.e. Gluten Free, vegan, dairy free... If yes, please specify:*
Please check all that you consume regardless of frequency:*

SodasCoffeeEnergy DrinksTeaAlcoholSmokeNone of the above
After eating a typical meal, do you feel or experience any of the following (check all that apply):*

BloatedGassySleepySatisfied-FullNot Satisfied-HungryOther
Do you take any vitamins, dietary supplements, herbs? If yes, please indicate what you currently take:*
If there is one thing that you could do to change your health, what will it be?*
Informed Consent

If you have a medical condition, always speak to your doctor before proceeding with any lifestyle change that may affect your health in a positive or negative way. It is ultimately up to you to decide on how to care for your health and wellbeing. We do not attempt to treat or address medical conditions or health issues that require medical attention. The information we provide is for educational purposes only. By your signature and/or submission of this form, you understand that we are not advising you to take any action or inaction with the information, services or products we offer and/or suggest to you. Our information is based on personal research, experience, training/educational programs and knowledge gained through our interaction with other clients like yourself.
Holistic Health Support

I, the undersigned, understand that Sacred Waters is not a medical facility and does not employ medical providers. The services I receive at Sacred Waters Wellness Arts Studio may be non-traditional or unconventional and are not for the purpose of treating disease or for replacement of medical needs. Such services are commonly referred to as complementary, integrative or alternative health services. Because many efforts may be necessary to resolve underlying difficulties in the body’s capacity to function, they are also known as “functional” techniques. These services may or may not be recognized as standard healthcare practices and may be considered investigative or experimental. If there is something that I do not understand, I will ask questions prior to submitting this form and/or proceeding with using services from Sacred Waters and/or it's representative.
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Holistic Health & Lifestyle Assessment

General Health

General Health Assessment

General Health Ratings

Lifestyle/Habits of Health

Dietary Habits

Informed Consent

Holistic Health Support