Lets Build Our Health

Lets Build Our Health

15 min FREE CONSULTATION
Welcome to the Let's Build Our Health Conversation Form!

Your health is a journey, and we're here to walk it with you. This comprehensive form is designed to delve into various aspects of your well-being, helping us understand the factors that may be influencing your health.

We acknowledge that the form is detailed, but each question serves a purpose. By providing thorough and honest answers, you enable us to offer personalized insights and support tailored to your unique needs.

Why Your Participation Matters:

Personalized Care: Your responses help us craft health strategies that resonate with your lifestyle and goals.

Holistic Understanding: By exploring different facets of your health, we can identify patterns and areas for improvement.

Empowered Decisions: Equipped with comprehensive information, you can make informed choices about your health journey.

Your Privacy is Our Priority:

All information you provide is confidential and will be used solely to enhance your health and wellness experience.

Let's Begin:

Take your time, answer what applies to you, and remember—each response brings us closer to understanding and supporting your health journey.

BUT BEFORE CONTINUING PLEASE READ BELOW THE CONSULTATION DISCLAIMER
CONSULTATION DISCLAIMER
IMPORTANT CONSULTATION ADVISORY
NATURE OF CONSULTATION SERVICE

The complimentary 15-minute educational consultation offered through Dr Herbaiist Dwight is provided strictly for:

Educational and informational purposes only
General discussion of traditional healing approaches
Cultural knowledge sharing
Wellness education

Professional Disclosure: I am a traditional herbalist, not a licensed medical doctor. My knowledge is based on cultural studies and personal experience, rather than medical training.

CRITICAL UNDERSTANDING
THIS CONSULTATION:

IS NOT:

Medical advice or treatment
A medical examination or diagnosis
A doctor-patient relationship
Professional medical consultation
Healthcare service provision
Therapeutic intervention

IS ONLY:

Educational discussion
Information sharing
Traditional knowledge exploration
General wellness conversation

PROFESSIONAL RELATIONSHIP CLARIFICATION
NO PROFESSIONAL MEDICAL RELATIONSHIP IS CREATED:

Dr Herbalist Dwight is not a licensed medical doctor
No medical practice is conducted
No therapeutic relationship is established
No medical services are provided
No professional healthcare obligations are assumed

CONSULTATION LIMITATIONS
DURING CONSULTATIONS, WE WILL:

Share educational information about traditional approaches
Discuss cultural healing practices
Provide general wellness insights
Offer traditional knowledge perspectives

WE WILL NOT:

Diagnose medical conditions
Prescribe treatments
Recommend specific medical interventions
Replace professional medical advice
Guarantee health outcomes

INDIVIDUAL RESPONSIBILITY
CONSULTATION PARTICIPANTS MUST:

Understand the educational nature of discussions
Maintain primary healthcare provider relationships
Seek professional medical advice for health concerns
Make informed personal health decisions
Take full responsibility for health choices

PROTOCOL RECOMMENDATIONS
ANY TRADITIONAL APPROACHES DISCUSSED:

These are for educational purposes only
Require healthcare provider review
Should be professionally evaluated
Must be medically supervised if implemented
They are not guaranteed to produce results

MEDICAL SUPERVISION REQUIREMENT
BEFORE IMPLEMENTING ANY DISCUSSED APPROACHES:

Consult your healthcare provider
Obtain medical approval
Ensure professional oversight
Monitor health status closely
Report any concerns to medical professionals

LIABILITY LIMITATION
DR. HERBALIST DWIGHT:

Disclaim responsibility for consultation outcomes
Provide no guarantees of health improvements
Assume no liability for individual health decisions
Offer information without warranties
Emphasize personal responsibility for health choices

EMERGENCY SITUATIONS
CONSULTATIONS ARE NOT APPROPRIATE FOR:

Medical emergencies
Acute health crises
Urgent medical needs
Serious health concerns requiring immediate attention

FOR EMERGENCIES, CONTACT:

Emergency medical services
Your healthcare provider
Appropriate medical facilities

BOOKING AND PARTICIPATION
BY SCHEDULING A CONSULTATION, YOU ACKNOWLEDGE:

Understanding of educational nature
Acceptance of personal responsibility
Agreement to seek professional medical care
Commitment to informed decision-making

FINAL ADVISORY
This consultation service is offered with deep respect for individual health journeys and the critical importance of professional medical care. Traditional knowledge sharing should always complement, never replace, qualified healthcare guidance.
Full Name

First NameLast Name
What is your age?
What is your gender?
Height
Weight
Contact Number
Email Address
example@example.com
Check the conditions that apply to you :

AsthmaCancerCardiac diseaseDiabetesHypertensionKidney DiseaseArthritisObesityGallbladder removalThyroid removal surgeryHysterectomy surgeryOther
What Is Your A1C?(Measures the amount of sugar in your blood)
What is Your EGFR? (Measures the percentage of your Kidney function)
Any Type of swelling in the body?

YesNo
If Yes where in the body
Any Surgeries?

YesNo
If Yes please list them with the year that you had them:
Check the symptoms that you' re currently experiencing:

Chest painRespiratoryCardiac diseaseCardiovascularHematologicalLymphaticNeurologicalGastrointestinalGenitourinaryWeight gainWeight lossMusculoskeletalDehydrationInsomniaPainErectile DysfunctionOther
Did You Take the COVID Vaccine?
Are you currently taking any medication?

YesNo
Please list them.
Do you have any medication allergies?

YesNoNot Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
How many bottles of 16 oz water do you drink per day?
What type of water do you drink?

SpringPurifiedDistilledAlkalineSmart Water
Do you consume any electrolyte replacements?( example Gatorade)

YesNo
Do you consume energy drinks?( example Red Bull)

YesNo
If yes what Brands?
Do you consume coffee?

YesNo
If yes what type and how many cups per day
Do you use added salt?

YesNo
If yes what type of salt and how much do you use?
How many meals a day do you consume?
Describe a typical breakfast
Describe a typical lunch
Describe a typical Dinner
Describe your snacks
Do you cook at home?

SometimesMost of the timesAll of the timeNot at all
Do you eat out?

SometimesMost of the timesAll of the timeNot at all
Do you consume any meal replacement Drinks?( example ensure)

YesNo
If yes what brands?

EnsureBoostOther
Do you consume protein Powders?

YesNo
If yes what brands?
What time do you typically eat your last meal?
Do you do any type of colon cleansing?(example: colon hydrotherapy (colonic irrigation), enemas ect

YesNo
If yes describe what type and frequency
Do you do any fasting?

SometimesNot at all
Do you exercise?

SometimesNot at all
How much sun exposure do you get on a typical day?
What time do you normally go to sleep?
How many pillows do you sleep with?
How may times do you wake up to urinate?
How often do you take a vacation?
Where Are You Filling Out This Form?(Office, Online, Event Name)
Best Date and time to review the form with you
Best Date and Time to review the form with you

MonthDayYear
Date
Hour MinutesAM/PM Option
Best Date and Time for a physical Appointment
Referred By
DR. HERBALIST DWIGHT https://mayanbotanicals.com/

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