Custom Healy Program Request

Consultation Request for Custom Healy Program(s) and/or Custom TimeWaver Session(s)

All of your information will be kept confidential.
Please note that the information on this form will be encrypted upon submission and will only be used for the purpose of scheduling and conducting a custom Healy program consultation and/or a custom TimeWaver Session. You will be contacted within 72 hours to schedule your session and payment will be due in full at the time of scheduling. The fee for your consultation will include 2 custom Healy Programs (fee under $200 USD). Additional custom programs will be available at a reduced add-on rate. TimeWaver session pricing will vary and will be discussed at the time of booking.

Please note: Filling out this form does not obligate you to schedule a session.

Your privacy is very important and none of your information will be shared; it will be used solely for the purpose of your consultation.
DO YOU UNDERSTAND AND AGREE WITH THE STATEMENT ABOVE?*

I Agree
WHICH TYPE OF SESSION ARE YOU INTERESTED IN BOOKING?*

Custom Healy ProgramsCustom TimeWaver SessionBothI'm not sure
PERSONAL INFORMATION
NAME:*

First NameLast Name
GENDER:*
AGE:*
DATE OF BIRTH:*

MonthDayYear
Date
BIRTH PLACE:*
BIRTH COUNTRY:*
ADDRESS:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
YOUR TIMEZONE:*
E-MAIL:*
RE-ENTER E-MAIL:*
example@example.com
PHONE NUMBER:*

Area CodePhone Number
RE-ENTER PHONE NUMBER:*

Area CodePhone Number
HEIGHT:*
CURRENT WEIGHT:*
WEIGHT 6 MONTHS AGO:*
WEIGHT 1 YEAR AGO:*
WOULD YOU LIKE YOUR WEIGHT TO BE DIFFERENT?*

YESNO
If you answered YES, please provide details here:
REFERRED BY:
SOCIAL INFORMATION
RELATIONSHIP STATUS:*
DO YOU HAVE CHILDREN?*

YESNO
If you answered YES, please provide details here:
DO YOU HAVE PETS?*

YESNO
If you answered YES, please provide details here:
OCCUPATION:*
HOW MANY HOURS DO YOU WORK PER WEEK AND WHAT ARE YOUR TYPICAL HOURS?*
HEALTH INFORMATION
PLEASE LIST YOUR MAIN HEALTH CONCERNS:*
OTHER CONCERNS AND/OR GOALS?*
AT WHAT POINT IN YOUR LIFE DID YOU FEEL BEST?*
PLEASE IDENTIFY ANY TRAUMATIC EVENTS (EMOTIONAL, MENTAL, AND/OR PHYSICAL) THAT YOU FEEL CONTRIBUTED TO THE ISSUE YOU WISH TO ADDRESS?*
ANY SERIOUS ILLNESSES OR HOSPITALIZATIONS OR INJURIES? IF YES, PLEASE INCLUDE DATES:*
HOW IS/WAS THE HEALTH OF YOUR BIOLOGICAL MOTHER?*
HOW IS/WAS THE HEALTH OF YOUR BIOLOGICAL FATHER?*
HOW IS YOUR SLEEP?*
HOW MANY HOURS DO YOU SLEEP?*
DO YOU WAKE UP AT NIGHT?*
If you answered YES, please provide details here:
DO YOU EXERCISE REGULARLY?*

YESNO
If you answered YES, please provide details here:
WHAT ROLE DO SPORTS AND EXERCISE PLAY IN YOUR LIFE?*
ANY PAIN, STIFFNESS, OR SWELLING?*

YESNO
If you answered YES, please provide details here:
ANY CONSTIPATION, DIARRHEA OR GAS?*

YESNO
If you answered YES, please provide details here (frequency or after certain foods):
ANY NON-FOOD ALLERGIES OR SENSITIVITIES?*

YESNO
If you answered YES, please provide details here:
DO YOU USE TOBACCO?*

YESNO
If you answered YES, please indicate if you smoke/chew, etc. and how often or how many cigarettes do you smoke per day?
DO YOU TAKE ANY DRUGS FOR RECREATIONAL PURPOSES?*

YESNO
If you answered YES, please list the drug and usage frequency:
MEDICAL INFORMATION
DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? PLEASE CHECK ALL THAT APPLY*

Acid RefluxADD/ADHDAllergiesAlzheimersAmalgam fillingsAnemiaAnxietyAsthmaArthritisArtificial Heart Valve or Heart Defect RepairAutoimmune DiseaseBleeding DisordersBlood ThinnersBronchitisCancerCardiac StentCerebral PalsyChemotherapy / RadiationCirrhosisCystic AcneCystic FibrosisCOPDDementiaDepressionDiabetes Type 1Diabetes Type 2Digestive ProblemsEmotional DisorderEmphysemaEpilepsy SeizuresFainting SpellsFibromyalgiaFracturesGallbladder DiseaseGallstonesGastrointestinal DiseaseGlaucomaGoutHeartburnHeart DiseaseHeart AttackHepatitis AHepatitis BHepatitis CHigh Blood PressureHIV / AIDSJaundiceJoint ReplacementKidney DiseaseLung DiseaseLupusMetal implants of any kindMigrainesMultiple SclerosisNeurological DisordersOsteoporosisPacemaker or Implantable DefibrillatorPanic AttacksParkinsonsProstate IssuesPTSDRheumatic FeverRheumatoid ArthritisUlcer DiseaseShortness of BreathSinus troubleSleep ApneaSnoringStrokeUse of a C-PAP deviceThyroid DiseaseTinnitusUlcersUlcerative ColitisVenereal DiseaseVertigoVitamin B12 DeficiencyOther
ARE YOU CURRENTLY WORKING WITH ANY HEALERS, THERAPISTS OR ANYONE ELSE ASSISTING WITH YOUR PERSONAL HEALTH GOALS?*

YESNO
If you answered YES, please provide details here:
ARE YOU CURRENTLY TAKING ANY SUPPLEMENTS OR MEDICATIONS?*

YESNO
If you answered YES, please provide details here:
FOOD INFORMATION
WHAT IS YOUR DIET?*

I EAT ALL MEATI EAT MEAT, BUT NOT RED MEATPESCATARIANVEGETARIANVEGANOther
ARE YOU DAIRY-FREE?*

YESNO
ARE YOU GLUTEN-FREE?*

YESNO
ARE YOU SUGAR-FREE?*

YESNO
DO YOU HAVE ANY FOOD ALLERGIES?*

YESNO
If you answered YES, please provide details here:
WHICH FOODS DO YOU OFTEN EAT FOR BREAKFAST?*
LUNCH?*
DINNER?*
SNACKS?*
LIQUIDS?*
HOW MANY MEALS DO YOU EAT PER DAY?*
DO YOU EVER SKIP MEALS?*

YESNO
If you answered YES, please list which meal(s) and why:
DO YOU COOK MOST MEALS OR EAT OUT?*

COOKEAT OUT
WHAT PERCENTAGE OF THE FOOD YOU EAT DAILY IS HOME-COOKED?
DO YOU TYPICALLY USE SALT?*

YESNO
HOW MANY GLASSES OF WATER DO YOU DRINK PER DAY?*
DO YOU DRINK COFFEE?*

YESNO
If you answered YES, approximately how many cups per day do you consume?
DO YOU DRINK ALCOHOL?*

YESNO
If you answered YES, how many drinks per week do you consume?
THE MOST IMPORTANT THING I SHOULD DO TO IMPROVE MY HEALTH IS:*
ADDITIONAL INFORMATION
ANYTHING ELSE YOU WOULD LIKE TO SHARE?
Healy is a microcurrent medical device that has been cleared by the U.S. Food and Drug Administration for relief of acute, chronic, and arthritis pain and muscle soreness due to overexertion. Healy also has non-medical applications that use individualized frequencies to help balance your mind and body and relieve stress. Always use your Healy in accordance with its Instructions for Use.
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Consultation Request for Custom Healy Program(s) and/or Custom TimeWaver Session(s)