• HEALTH & WELLNESS ASSESSMENT

    IMPORTANT DISCLAIMER The health information received during this consultation is for general education and is not intended to be specific medical advice. No medical care, diagnosis, or treatment is provided during this consultation. It is advisable to consult with one's personal health care provider before implementing any lifestyle changes. I release The Creator's Nature Blend Herbals Lifestyle Counselors or associated organizations from any and all liability. Participation in this consultation indicates acceptance of these terms. Signature (type full name) and Date are required.

  • General Information

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • When Did You Last Consult a Physician?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are You Currently Being Treated for Any Ailments?
  • Are You Vaccinated with Any Covid-19 Vaccinations?
  • When Were You Last Vaccinated?
     - -
    2 digit month, 2 digit day, 4 digit year
  • EMOTIONAL / MENTAL DISORDERS (Select all that apply)
  • CURRENT SYMPTOMS (Select all that apply)

  • Personal Stats

  • Sex

  • Pure Air

  • Where do you live?
  • Do you sleep with your windows open?
  • Do you open your windows or doors daily to air out the home?
  • Do you live or work in a smoke-filled environment?
  • Do you have any smokers living in your home?
  • Do you have live plants throughout your home?
  • Are there any environments you are in that do not have a good supply of fresh air?
  • Do you wear tight fitted clothing that restricts your lung expansion?

  • Sunlight

  • Do you sunbathe?
  • Do you wear short sleeves?
  • Do you use sun block?
  • Do you have any unusual sensitivity to sunlight?
  • Do you take vitamin D supplements?
  • Do you have any family history of skin cancer?

  • Abstemiousness

  • Do you smoke or use tobacco products?
  • Have you used tobacco in the past?
  • Do you use alcohol in any form?
  • Do you ingest caffeine in any form?
  • Do you overeat?
  • Do you eat too fast?
  • Do you chew your food thoroughly?
  • Do you snack between meals?
  • Do you eat at set meal times?
  • Would you say your dress is healthful and modest?
  • Do you overwork?
  • Have you been involved with substance abuse?
  • Do you read novels, science fiction, pornography, fashion magazines, or play computer games?
  • Do you attend cinemas, dances, night clubs, house parties, or amusement parks?
  • Do you play any competitive sports?

  • Rest

  •  :
  • Do you wake up during the night?
  • Do you snack before you go to bed?
  • Do you sleep with the lights on?
  • Do you work the night shift or swing shift?
  • Do you wake up early and find it difficult to get back to sleep?
  • Do you take sleeping pills?
  • Do you make it a practice to get to bed at a certain time?
  • Do you rest from labor at least one day per week?

  • Exercise

  • Do you exercise?
  • How would you rate your exercise?
  • Do you experience any pain while exercising?

  • Proper Diet

  • Do you eat meat or flesh items?
  • Do you eat dairy items or eggs?
  • Do you eat refined white products?
  • Do you use condiments?
  • Do you add spices?
  • Do you eat fried foods?
  • Do you use margarine or butter?
  • Do you use baking powder or baking soda?
  • Do you eat fresh bread?
  • Do you eat or drink cocoa, chocolate, or ice cream?
  • Do you read labels on food items you buy?
  • Do you eat any canned items?
  • Are you on any special diet?
  • Do you eat out?
  • Do you use salt?
  • Does the salt contain iodine?

  • Water

  • Is your water filtered?
  • At what temperature do you usually drink your water?
  • Do you eat ice?
  • Do you drink with your meals?
  • What color is your urine normally?

  • Trust in Divine Power

  • Do you have a daily devotional time?
  • If no, would you like to have one?
  • Do you spend time reading the Bible daily?
  • Do you return a faithful systematic tithe and offerings?
  • Do you have difficulty trusting the Lord with your problems?
  • Do you suffer any remorse, guilt, worry, or fear at present?
  • Do you believe that you have experienced the forgiveness of God in your life?
  • Do you struggle with knowing God's will for your life?
  • Would you consider your family to have good relations with each other?
  • Do you have a spiritually strong immediate family?
  • Do you have peace with God and your fellow men?
  • Have you broken any vows or promises to God that is within your power to fulfill?
  • If the Lord were to come today, knowing the life you are currently living, would you be saved?
  • Should be Empty: