• Holistic Health & Lifestyle Assessment

    Holistic Health & Lifestyle Assessment


  • General Health



  • 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.
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  • 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.
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  • Lifestyle/Habits of Health

  • 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.

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


  • 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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