Health Assessment & Consultation Includes:

Comprehensive health intake questionnaire
One-on-one health and wellness consultation (60 minutes)
Personalized analysis and feedback based on your intake form and relevant data
A fully customized 90-day health and wellness care plan
Nutritional, herbal, and supplement recommendations tailored to your specific needs
Personalized juice therapy options based on your condition
Lifestyle and exercise recommendations as part of a holistic, wholistic approach to wellness

Consultation Fee & Follow-Up Care

Your initial consultation requires a non-refundable fee of $200, which must be submitted along with this completed form. This fee covers your complete health assessment, consultation session, and personalized wellness plan.

While you may receive occasional check-in calls from our office, we highly recommend 30-day follow-up appointments for continued support. These follow-up sessions are available at $45 for 20 minutes.

Please note that additional costs may apply for any recommended herbal formulas, supplements, or produce that support your wellness journey. A detailed cost estimate for your full 90-day program will be shared once your plan has been finalized.

Consent, Disclosure & Disclaimer

Congratulations on taking this vital step toward creating a healthier life for yourself. This health intake form and consultation are designed for educational and wellness-support purposes only. They are not intended to diagnose, treat, or prescribe any medical or psychological condition, disorder, or disease.

All information provided and recommendations made are intended to empower you with knowledge and guidance. Any actions taken based on this consultation are made at your own discretion and in response to your personal request for support.

By submitting this form, you acknowledge that you understand and agree to the above terms.

Address *

Street Address

City

State

Country

Postal code

Do you have or have you had any of the following? Place a number in the space provided that best describes each condition. 0 = Never 1 = Rarely 2 = Occasionally 3 = Sometimes 4 = Most of the time 5 = Always *

Absent Minded
Acne
Alcoholism
Allergies
Anemia
Appendicitis
Arthritis
Asthma
Bad Breath
Cancer
Chest Pains
Chills/Cold Skin
Cold Hands/Feet
Constipation
Crave sweets/coffee
Depression
Diabetes
Diarrhea
Difficulty Breathing
Digestive Disorders
Dizziness
Eat When Depressed
Eat When Nervous
Eat to Relieve Fatigue
Eczema
Emphysema
Excessive Hunger
Excessive Fear/Worry
Faint When Hungry
Fatigue
Feel Shaky when Hungry
Foul Smelling BM
Foul Smelling Urine
Frequent Colds
Frequent Kidney Infections
Frequent Lower Bowel Gas
Frequent Urination
Gallstones
Hay Fever
Headaches
Heart Disease
Heart Pounds Hard
Hemorrhoids
High Blood Pressure
Hot Most of the Time
Indigestion/Heartburn
Insomnia
Irritable before Meals
Itching of the Nose
Itching of the Rectum
Kidney Stones
Low Blood Pressure
Lumbago
Mental Disorder
Motion Sickness
Nausea
Nervous Disorder
Night Blindness
Pain w/ Bowel Movement
Poliomyelitis
Prostate Trouble
Respiratory Problems
Rheumatic Fever
Sexual Disorders
Sinusitis
Skin Problems
Sluggish in the A.M.
Swollen Glands
Too Fast Digestion
Tuberculosis
Ulcers/Colitis
Venereal Infection
Wake Up Tired
Weight Problem

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Soda
Coffee
Tea
Fruit Juice
Punch
Milk
Other

Health Assessment & Consultation Includes:

Consultation Fee & Follow-Up Care

Consent, Disclosure & Disclaimer

Optimal Sleep Rejuvenation

Optimal Pro-life Selection and Moderation