Science of Human Optimization
Confidential Assessment Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Current Weight / Height
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
1. What is your main health goal?
2. Was there a stressful life event that you believe affected your wellbeing?
Yes
No
3. How has this condition affected your lifestyle?
4. What are the top three foods you eat daily and / or crave?
5. What medication / supplements are you taking now?
6. Have you gained (or lost) weight inexplicably and have trouble loosing weight no matter how you eat or exercise?
7. Do you believe there is a permanent resolution to the underlying cause?
Yes
No
8. Would you be willing to adjust your diet, take the recommended supplements, adhere to a detoxification program, or an intravenous therapy schedule, as part of the treatment plan?
9. Do you currently have amalgam (mercury) fillings?
Yes
No
10. Have you ever had a root canal, implant, or major dental work done?
Yes
No
11. Would you be willing to go through an educational program to understand the lifestyle and nutritional protocols for optimal function and longevity?
12. On a scale of 1-10 how committed are you to optimizing your mind and body for peak level function?
Is there anything else you would like us to know that may offer insight in helping you achieve your health goals?
When Is the Best time for you to meet with your ScHO Practitioner?
AGREEMENT
We are NOT looking to diagnose or treat any particular disease, or condition.
Our focus is to identify deficiencies, toxicity, and/or a compromised system of digestion that may be interfering with peak-performance function.
This program is not something we do to you but with you, and together, we'll work to achieve the most satisfying outcome for the effort invested.
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