Health Assessment Form (Hayley Porter)

Health Assessment Form

Please send your intake form and photos in one email for organization purposes. Use as much space as you need in each section! Know that ALL information you provide will be kept confidential throughout this entire process. Thank you!
Name

First NameLast Name
What type of appointment did you book?
Current date:
Country or town name:
Email
example@example.com
Age and date of birth, time and location if known:
Human Design + any astrology information (if known)
Referred by:
What do you want/need from this analysis?

Daily Diet

Please describe your daily diet in detail, make sure to include previous diets verses current.
Morning drinks:
Breakfast:
Mid-morning:
Lunch:
Afternoon:
Dinner:
Evening food and drinks:
Cravings and "cheat foods":
Allergies and/sensitivities:

Health History

Please describe your past health history (please list dates as well).
Injuries:
Surgeries:
Illnesses:
Traumas:
Record of Medications (please list start and end dates andreason for taking):
Are you taking any herbs or supplements? (please list all)
Health of Parents

Please complete this section to the best of your ability.
Mother:
Father:
Maternal Grandmother:
Maternal Grandfather:
Paternal Grandmother:
Paternal Grandfather:
Current Symptom Profile

Please describe the following, in DETAIL.
List ALL of your current symptoms, regardless of how “minor” they are:
Sleeping habits:
Bowel Movements (how frequent):
What do you do for exercise?
Skin and complexion:
Eye Sight:
Hearing:
Energy Levels (please be descriptive with each time of day):
Hair and scalp:
Nails (texture and markings):
Teeth:
What does your tongue look like? Please describe :
How are your feet?
Height/Weight:
Blood Type (if known):
WOMEN: Please describe your menstrual cycle, hormones, libido, and any current or past use of contraceptives.
MEN: Please describe your levels of libido and prostate gland.
Current emotional states, moods and stress levels:
Are you right or left handed?
Favorite color?
Favorite season?
Are you in a relationship? Please describe:
Do you have children? Please describe:
Do you have pets? Please describe:
Please describe your living situation:
Past and present occupation?
Please describe your work and environment:
Any other information about your health, body systems, emotions or spirit? Please note:

Required Photos

Please submit these photos to hayley@schoolofiridology.com prior to your session.
Tongue Photos

Please take 3 photos of your tongue.
- one in the morning before brushing your teeth
- one mid day
- one in the evening before brushing your teeth.
Hands + Feet Photos

Please also take photos of your hands, fingernails and feet.

Face + Body Photos

Please send a photo of your face (feel free to smile!) and a photo of your entire body. You should be clothed for this photo.

Iris Photos

Please read the instructions below for how to take your iris photos.
- Please send one photo of each eye. Only send 2 each
  at maximum and please send them together in one email!
- For your iris photos, you will need a friend to help you. Have your friend hold a smartphone camera in one hand and a flashlight in the other hand. They will hold the phone camera close to and directly in front of your eye.
- The flashlight will need to illuminate from the side at a 45 degree angle.
- Place a scarf or blanket over both of your heads to cancel out any lighting or reflections, creating a mini dark room.
- Stare straight into the camera.Take one photo of each eye. Hold the eyes wide open. Use your own hands to
  open your eyes so the whole iris is visible, if needed.
- The goal is to have the iris clear, so that I can see the fibers.
- Do not worry about the skin of the face being clear or visible. Only the eye is of importance.
- Please do not zoom as this lessens the clarity and creates pixilation.

Medical Disclaimer

Please read through this entire medical disclaimer and sign prior to submitting your health assessment form.
All information/content provided by Hayley Porter (@iridology.with.hayley) is not intended to replace that of a licenced and registered health care provider.

Any information shared by Ms. Porter including (but not limited to) diet, nutritional, herbal, homeopathic, fasting, or any other health modalities, is solely for educational purposes and does not involve or include diagnosing, prognosticating, treatment, or prescribing of remedies for the treatment of diseases and should not be considered a substitute for medically necessary diagnostics.

Those purchasing consultations or other content provided should understand that no ‘doctor-patient’ relationship exists, rather an at will educational and empowering mutual relationship. It is a personal responsibility of each participant to consider the advice and recommendations offered by Ms. Porter, and to become educated as to the efficacy, risks and desirability of any information provided.

Ms. Porter does not accept responsibility for accidental or intentional misuse of the opinions expressed in produced content or in consultations/correspondence, or the consequences which may arise from such.
Please type your full name to acknowledge and electronically sign this waiver.
Date

MonthDayYear
Date
Should be Empty:

Health Assessment Form

Daily Diet

Health History

Health of Parents

Current Symptom Profile

Required Photos

Medical Disclaimer