Holistic Health Intake Form

Holistic Health Intake Form

Please share your health needs and concerns in as much detail as possible. All information you provide will remain strictly confidential.
Name

First NameLast Name
Email
example@example.com
Age + Date of Birth
What do you want/need from this analysis?

Food Intake

Please describe your daily diet in detail and esure to include previous diets verses current.
What food lifestyle do you follow?
pescatarian, vegetarian, meat eater, raw etc
General breakfast / lunch + drinks
General dinner + drinks
Cravings / cheat foods
Allergies and Sensitivities

Health History

Please describe your past health history (please list dates as well).
Injuries:
Surgeries including dental:
Illnesses or infections in the mouth:
Please share any spiritual, sexual, or emotional traumas you feel are important for me to know:
Record of Medications (please list start and end dates and reason for taking)
Are you taking any herbs or supplements? (please list all)

Health of Parents

Please complete your families past history to the best of your ability.
Father, Grandmother + Grandfather:
Mother, Grandmother + 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 and how often?:
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 toe nails?:
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:
Lifestyle
Do you have children? Please describe:
Do you have pets? Please describe:
Please describe your living and work situation/environment:
Past and present occupation?
Any other information about your health, body systems, emotions or spirit?:

For the Iridology Call ONLY (Ignore This Page + Click SUBMIT if You're Only Doing Consultation Call)

Please email your photos with your full name as the subject 72 hours prior to the call divinebynaturehealth@gmail.com
Iris Photo

Please send one clear photo of each eye — a maximum of 2 photos in total — and attach them together in one email.

How to take your iris photos:
- Ask a friend to help you. They’ll need a smartphone camera in one hand and a flashlight in the other.
- Have them hold the phone close and directly in front of your eye.
- Position the flashlight at a 45-degree angle from the side so it lights the iris evenly.
- To reduce glare and reflections, do it in a dark room.
- Look straight into the camera. Hold your eye wide open - use your fingers to open your eye so the entire iris is visible.
- The focus should be on making all the markings as clear as possible like the photo below.
Please watch tutorial here > https://youtube.com/shorts/chWnVrpdPw4?si=azBAcpLFSfXqnQnB

Optional

Tongue Photos
Please take three photos of your tongue in the same natural lighting:

- First thing in the morning, before brushing your teeth
- Midday
- In the evening, before brushing your teeth

Hands + Feet Photos
Please take clear photos of your hands (including fingernails) and your feet.

Face + Body Photos
Please send one clear photo of your face and one full-body photo. Clothing should be worn for the full-body photo.
Should be Empty:

Food Intake