Holistic Health & Lifestyle Assessment
First Name
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Last Name
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Phone Number
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E-mail
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Mobile Number
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
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Connecticut
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District of Columbia
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New York
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
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State
Zip Code
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
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31
Day
Please select a year
2025
2024
2023
2022
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2020
2019
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1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Height
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Weight
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Approximate or Best Guest
What is your ideal weight or where do you feel the healthiest?
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Marital/Family Status
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Single
Married/Partner
Divorced
Widow
Children
I am a minor
Children
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Yes
No
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
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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?
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Detox/Cleanse Support
Lifestyle/Wellbeing Support
Weight Loss Support
Colon Hydrotherapy/Colon Cleanse
Gut Health Support
Energetic Health Assessment
Workshop/Classes
Other
What is your current health and wellness goal?
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General Health
How often do you have a bowel movement?
3 Daily
2 Daily
1 Daily
1-3 Weekly
Other
Have you ever had professional Colon Hydrotherapy before?
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Yes
No
If yes, specify approximate date:
Have you had a surgical procedure within the last year? Please reply YES or NO. If yes, please explain:
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Do you have any physical complaints or symptoms? Please reply YES or NO. If yes, please explain:
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Any diagnoses of chronic disease?
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Yes
No
Other
Do you take any medications daily? If yes, please list the conditions only:
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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?
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Excellent - Never sick, no complaints
Good - Sick once per year, only minor complaints
Fair - Sick more than once a year, occasional symptoms
Poor - 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?
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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?
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Are you open to learning more about holistic health or alternative medicine and how it may assist you in improving your health?
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Yes
Unsure
Not interested in learning about holistic health.
Have you ever experienced a guided detox or cleanse with a natural health professional or holistic health coach?
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Yes
No
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?
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Excellent
Good
Fair
Poor
How many hours of sleep do you get nightly?
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Do you feel rested when you wake up?
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Yes
No
Do you feel like you're under stress? If so, explain:
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How often do you exercise?
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Daily
Weekly
Occasionally
Never
What type of exercise, if any?
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How much water do you drink daily?
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What type of water do you drink?
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Tap
Bottle
Other
None
After drinking water, do you ever feel bloated
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Yes
No
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?
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Whole and Clean Foods Daily
Whole Foods Most Days, Needs Improvement
Standard American Diet
My 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?
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Do you have any food allergies? If yes, which foods?
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How many meals or how often do you eat in a day?
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How many days a week do you dine out?
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1-2
3-5
6-7
None
How much do you or your household spend on dining out weekly?
$200 or more
$100-$200
$25-$100
Less than $25
What if any, keeps you from cooking at home (check all that apply)?
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Lack of time
Lack of energy or enthusiasm
Lack of cooking ability/meal ideas
Prefer to eat out
I already cook a lot
Other
Please mark how often, if any you eat the items below:
Red Meat
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Daily
Weekly ( 1 to 2 meals)
Occasionally
Never
Seafood
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Daily
Weekly (1 to 2 meals)
Occasionally
Never
Chicken/Turkey
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Daily
Weekly (1 to 2 meals)
Occasionally
Never
Other meat
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Daily
Weekly (1 to 2 meals)
Occasionally
Never
Green Leafy-Uncooked Vegetables (including salads)
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Daily
Weekly (1 to 2 meals)
Occasionally
Never
Cooked Vegetables
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Daily
Weekly (1 to 2 meals)
Occasionally
Never
Fast or Processed Foods
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Daily
Weekly (1 to 2 meals)
Occasionally
Never
Fresh Fruit
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Everyday
Weekly (3 or less servings)
Never
Juicing/Smoothies
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Daily
Weekly (1 to 2 meals)
Occasionally
Never
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.
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Daily
Weekly (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:
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Sodas
Coffee
Energy Drinks
Tea
Alcohol
Smoke
None of the above
After eating a typical meal, do you feel or experience any of the following (check all that apply):
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Bloated
Gassy
Sleepy
Satisfied-Full
Not Satisfied-Hungry
Other
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?
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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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