Isola Wellness Herbalism & Iridology Consultation Questionnaire

Please list your primary health concerns and/or wellness goals

Full Name*

First NameLast Name

Date of Birth*

Date

Gender*

Contact Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Disclosure and Informed Consent

Email Address

example@example.com

If yes, please list your allergies

Are you currently taking any medications?*

YesNo

If yes, please list your current medications (include dosage and frequency)

Do you have any chronic medical conditions? (e.g., diabetes, hypertension, asthma)*

YesNo

If yes, please list your chronic conditions

Have you had any surgeries or hospitalizations?*

YesNo

If yes, please provide details (type, date, outcome)

Family Medical History: Do any of your immediate family members have a history of significant illnesses? (e.g., heart disease, cancer, diabetes)

Do you smoke?*

YesNoFormer smoker

Do you consume alcohol?*

YesNoOccasionally

How often do you exercise?

Is there anything else about your health history you would like to share?

Occupation

Stress Level at Work

LowModerateHighVery High

Marital Status

MarriedNot Married

Do you have children?

YesNo

Upload Images

Please upload clear images relevant to your consultation.

DISCLOSURE & INFORMED CONSENT FORM

I hereby attest to the following:

1. I fully understand that Herbalists of Isola Wellness are not licensed medical doctors/practitioners and do not diagnose, treat or cure any illness, disease or pathology health condition nor prescribe medicine or pharmaceutical nor represent as doing so.

2. The services provided by Isola Wellness, whether in person or by email or phone or video are at all times restricted to consultation on the subject of wellness and health assessment. These services are solely intended to provide resources to promote my own health and well-being. Their services do not involve diagnosing, treatment, or prescription for the treatment of disease.

3. I recognize that no claims are made for the herbal products, supplements, nutritional or dietary recommendations offered by the Herbalists of Isola Wellness and are not intended to treat, cure or prevent any illness or disease. If you have or suspect that you have a medical problem, consult with your physician for diagnosis or treatment. Use products as per instructions, if there is any adverse or allergic reaction of any sort, discontinue use and consult your Herbalist and your Medical Professional. You should always carefully read all product packaging and labels. Always consult your physician or health care provider before using any herbal products, especially if you are pregnant, have a medical problem or on medication.

4. Isola Wellness assumes no liability for any injury, illness or adverse effects caused by the use and/or misuse of the information or products recommended. There is no implied or stated guarantee of success or effectiveness of any specific herbal products or wellness plan. All informational material, descriptions and representations that have been provided by the manufacturers of products are subject to change. Isola Wellness cannot, and will not, assume any liability for any manufacturers descriptions of these products or for inaccuracies or misstatements about any herbal or supplemental products provided.

5. I fully understand that it is my constitutional right to decide how I wish to care for my health and assume all responsibility for decisions I make regarding my health. Isola Wellness nor their Herbalists have not suggested that I cease current medical care I am receiving, be it drug therapy, x-ray treatments, chemotherapy/radiation therapy, surgery, or any other medical procedures that my medical doctor or any other health practitioner deems necessary for my health. If I choose not to follow the recommendations made by my medical doctor or other practitioners, I understand that such a decision is my responsibility and will not hold any other persons responsible for any consequences of such a decision.

6. Statements made regarding the herbal and natural products offered by Isola Wellness have not been evaluated by the Canadian Food and Drug Administration, nor the US Food and Drug Administration. Statements do not claim that these products have gone through the rigorous double-blind studies required before a particular product can be deemed truly beneficial or potentially dangerous and prescribed in the treatment of any condition or disease.

7. I am here, on this and any subsequent visit, solely on my own behalf and not as an agent for federal, state or local government agencies on a mission of entrapment or investigation.

8. I understand that all information discussed will be kept strictly confidential. I hereby release the Herbalist(s) (Emily Miiller) and Isola Wellness from all responsibility for my actions and any consequences therefore in the present time and the future with no constraints. I hereby affirm that I consent and agree to the above statements of my own free will and request to engage the services of Isola Wellness in a professional relationship to the statements herein.

Signature*