Holistic Wellness Assessment

Holistic Wellness Assessment
Full Name

First NameLast Name
What is your age?
What is your gender?
Contact Number
Email Address
example@example.com
Marital Status

MarriedDivorcedSingleWidowed
How many children do you have?
What conditions/symptoms are you experiencing at the present moment? List in order of priority.
What do you believe is causing your most important health concern?
Are you in pain right now? If yes, what area are you experiencing pain?
If yes, when did the pain start?
Check the conditions that apply to you:

AsthmaCancerCardiac diseaseDiabetesHypertensionMental IllnessEpilepsyHeadaches/migrainesEye sight blurryHearing lossSinus IssuesDry ThroatIBSDigestive IssuesChronic ConstipationChronic diarrheaOther
If you checked other, please list
Check the symptoms that you' re currently experiencing:

irritability/angerHeadaches/migrainesgall stonesblurred visiondepression/stressVision issuesdizzinessfeeling of lump in throatanxietydry,red,itchy eyesWeight gainWeight lossvision problemsClenching teethmuscle cramping or twitchingtensionjoints,neck,shoulder painpoor circulationsoft,brittle nailsemotional eaterringing in earseczemaindecisiveheart palpitationschest paininsomniaeasily startledrestlessness/agitationvivid dreamslack of joy in lifedry scalpskin rashcyststumorear infectionsore throatswollen lymph node(s)hot palms/feetnose bleedsthirstfatigueedema (swelling)easy bruisingbad breathdecreased appetitecrave sweetshypoglycemianausea/vomitinggas/belchingheartburnoverthinkingexcessive worryfood allergysinus troublehivessnoringgrief/sadnessshortness of breathasthma/allergieslow resistance to colds/flusneezingcough with sputumurinary problemsbladder issuesweakness/pain in lower backdecreased bone densityfeel cold easilylow sex driveexcess sexual drivepoor memoryloss of hairhearing problemscavities/tooth losscrave saltcrave sugarfearhot flash/night sweatsdark under eyesweak legs/kneesthyroid problems
Are you currently taking any medication or vitamins/suppliments?

YesNo
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 ounces of water do you consume daily?
Do you have dietary restrictions?
Do u have allergies to any essential oils, herbs, or supplements? If yes, Please list
Do you exercise regularly?

YesNo
If yes, what type of exercise?
On a scale 1-10, 1 being the lowest & 10 being the highest, how stressed are you?
What do you do to try to release stress or just relax?
How many hours of sleep do you average per night?
What time do you typically go to bed?
Do you wake feeling refreshed?
What is your present weight?
What is your height?
Are you willing to let go of emotions to help with healing?

yesno
Your healing may require trials of herbal remedies, essential oils, frequencies, teas, supplements, vitamins, meditation, sound therapy, energy healing (reiki, in person healing sessions. Is there any of these you do not want to include?
Is there anything else you want to add that will help with your assessment?
Holistic Therapy Consent & Release Statement

Holistic involves natural methods and suggestions to release emotions, use herbal remedies such as herbs, oils, essential oils, supplements, and vitamins.

I understand very clearly that these treatments are not intended as a substitute for medical or psychological care but can be used in addition to treatments.

I understand that Holistic practitioners do not diagnose conditions, nor do they prescribe medicines, nor interfere with the treatment of a licensed medical professional. It is recommended that I seek a licensed health care professional for any physical or psychological ailment I have.

I, the undersigned, understand that the detailed therapy regimen based on my holistic wellness assessment will be provided with a summary of ideas to help with your individual healing. This is an “at will” summary meaning that Daizes, Stacey Miller, and all associates and staff cannot be held liable for any treatments that do not work, that cause reactions, or cause any other reaction to the body, mind or spirit.

I fully release, waives discharges & covenants not to sue Daizes, Stacey Miller or employees from any and all losses, causes of action, claims, damages, or liability that Participant, Participant’s Spouse, Child(ren), guests, legally authorized representative, assigns successors and representatives may have that relates to, arises out of or is any way connected to Participant’s use of the Center or participation in center’s activities

"I understand that while holistic therapies are generally safe, they may not be suitable for everyone and could potentially interact with current medications. I agree to discuss any concerns or changes in my health with the practitioner immediately."
Signature

Powered by Jotform SignClear
Should be Empty: