• Holistic Health & Lifestyle Assessment

    Holistic Health & Lifestyle Assessment

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Marital/Family Status*
  • Children*
  • Which service(s) are you interested in?*

  • General Health

  • How often do you have a bowel movement?

  • Have you ever had professional Colon Hydrotherapy before?*
  • Any diagnoses of chronic disease?*

  • 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
    Rows
  • How do you rate the overall quality of your health?*
  • How do you rate the overall quality of your emotional/mental well-being?*
  • Are you open to learning more about holistic health or alternative medicine and how it may assist you in improving your health?*
  • Have you ever experienced a guided detox or cleanse with a natural health professional or holistic health coach?*

  • 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
    Rows

  • Lifestyle/Habits of Health

  • How do you rate your overall energy level on a daily basis?*
  • Do you feel rested when you wake up?*
  • How often do you exercise?*
  • What type of water do you drink?*
  • After drinking water, do you ever feel bloated*

  • 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?*
  • How many days a week do you dine out?*
  • How much do you or your household spend on dining out weekly?
  • What if any, keeps you from cooking at home (check all that apply)?*

  • Please mark how often, if any you eat the items below:

  • Red Meat*
  • Seafood*
  • Chicken/Turkey*
  • Other meat*
  • Green Leafy-Uncooked Vegetables (including salads)*
  • Cooked Vegetables*
  • Fast or Processed Foods*
  • Fresh Fruit*
  • Juicing/Smoothies*
  • 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.*
  • Please check all that you consume regardless of frequency:*
  • After eating a typical meal, do you feel or experience any of the following (check all that apply):*

  • 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.
  • Should be Empty: