Name *

Age *

Phone *

Email *

Please share what inspired you to pursue taking care of yourself in this way, what's going on with you? What health concerns do you have? *

What are your goals in the realms of body/mind/spirit by making this commitment to yourself? How important are they? Rate 1-10 *

Please share a day in the life of self-care that you offer yourself now. i.e. How often do you eat fast food, drink soda, exercise, etc.

How is your energy now? If ten was perfect, what range are you in? Are there times during the day when you crash?

Are you getting a good sleep? How many hours per night? Do you dream? Do you wake up feeling well rested?

How is your Digestion? *

How often do you have a BM?

Do you get easily bloated/constipated/loose unabsorbed stool?

Indigestion or other discomfort? How often? How Severe?

Have you had any diagnostic scans or testing done in the last 5 years? If so, what results?

Are you dealing with joint or other pain in your body?

Skin issues? Please describe

Brain fog? How often? How Severe?

Headaches? How often? How Severe?

How many cups of coffee or other caffeine drinks per day?

Cups of Coffee

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Do you Do Dairy?

Do you have weight that you would like to release or other goals for how you wish for your body to feel? *

If you wish to release weight, what is your starting weight today? *

How much weight would you like to release ideally long-term? *

Any Medically Diagnosed or Self-Diagnosed Conditions? *

Are you low thyroid or hyperthyroid?

Do you have any food, seasonal, or other allergies? *

List your Medications *

If you are on Blood Thinners, we will have you abstain from the Apothe-Cherry.
If you are on Blood Pressure Medications, I recommend speaking with your doctor to get a guideline for when to take, reduce, or hold your blood pressure meds. As you progress on this system, you may reduce your need for the medication, so I recommend taking your blood pressures each day before you take your blood pressure medication.

Blood Sugars: A1-C History

If you are on Diabetic Medications, I recommend speaking with your doctor to get a guideline for when to take, reduce, or hold your meds. As you progress on this system, you may reduce your need for the medication, so I recommend taking your blood sugars before you take your medication.

Baselline (Usual) Blood Pressure

Cholesterol levels

C-Reactive Protein?

Protein?

Yes
No
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This is the marker for inflammation in your body and if you've never had it before, I recommend asking your doctor to run this test for you each time you have blood drawn

Any other out of the normal range Lab Results?

How's your mental/emotional health? Rate your satisfaction 1-10

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Are you open to discussing timing some colon hydrotherapy sessions during these first 30 days to accelerate your cleansing results?

Yes / Not Now

Yes
Not Now
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Would you like to discuss booking an Integrative Reiki/Life Coaching Session with me to help you with mindset and removing energy blocks, limiting beliefs, and emotional toxicity as well as physical toxicity?

Yes / Not Now

Yes
Not Now
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Congratulations on starting your journey to improved wellness!

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