Holistic Healing - Client Form Step 1 of 2 50% Name First Last Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneCell PhoneEmail The Top 3 symptoms you want relief from (see the second page)How much sweaty activity weekly? What type of activity? How many ounces of water do you drink daily? What type of water? (Ex. tap, spring, distilled RO) How many meals per day are you eating? Which of the following do you consume daily, weekly or monthly. Soda Coffee Alcoholic Bev. Fast food Dairy Added Sugar Raw fruit Meat Whole Grains White Flour Raw Veggies Smoking What kind of foods do you crave and how often? What are your favorite foods? How many eliminations daily do you have? Do you take any vitamins or supplements? How much energy do you have daily?1 being the lowest and 10 being the highest12345678910Are you currently taking any prescription medications? Have you ever had any surgeries? Have you had any injuries? If yes then what and how long? What are you not willing to do? What foods do you dislike? How many hours of TV do you watch daily? How many hours each day or week do you spend with family, loved ones or friends? How many hours of sleep do you get each night? Is your sleep quality good? Do you practice any meditation, prayer, go to church or any other spiritual practice? How did you hear about us? (referral, online) I understand that I am here to learn about nutrition and better health practices and that I will be offered information about food supplements and herbs as a guide to general good health. I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purposes or treatment procedures. I am not on this visit or any subsequent visit an agent for federal, state, or local agencies or on a mission of entrapment or investigation. The services performed here at all times are restricted to consultation on holistic and nutritional matters intended for the maintenance of the best possible state of natural health and do not involve the diagnosing, treatment or prescribing of remedies for disease.Signature(Required)Date(Required) MM slash DD slash YYYY Areas or Symptoms of Concern (Check all that apply) Acne Bruises Diarrhea ADD/ADHD Burns Digestion Adrenal Glands Cancer Dizzy Spells Allergies Candida Ear Infection Anemia Canker Sores Ear Ringing Anger Carpal Tunnel Edema Anxiety Cataracts Emphysema Arthritis Chest Congestion Epilepsy Asthma Chest Pain Eyesight Back Pain Cholesterol Fatigue Bad Breath Circulation Fever Bed Wetting Cold-Common Flu Bell’s Palsy Cold-Temperature Gallstones Bites Colic Gangrene Bladder Colon Gas High Blood Pressure Constipation Gout Low Blood Pressure Cough Gums Boils Cravings Hair Issues Bones Dandruff Headache Breathing Depression Heart Issues Bronchitis Diabetes Heartburn Hemorrhoids Lymph Glands Rheumatism Herpes Menopause Ringworm Hiatal Hernia Menstrual Cramps Seizures Hives Migraines Shingles Hormones Mononucleosis Sinus Hyperactive Mucous Skin Issues Hypertension Nails Snoring Hyperthyroidism Nausea Sore Throat Hypoglycemia Nervousness Stomach Impotence Nose Bleeds Stress Incontinence Parasites Stroke Indigestion Parkinson’s Disease Sty Insomnia Perspiration Teething Joint Pain PMS Tennis Elbow Kidney Issues Pneumonia Tonsillitis Kidney Stones Polyps Tumors Laryngitis Pregnancy Ulcers Leprosy Prostate Urinary Infections Leukemia Psoriasis Varicose Veins Liver Rash Vertigo Lung Issues Reproductive Overweight Underweight Lupus Respiratory Yeast Infections Other Other
