Vitality Wellness Assessment

One's health and well-being are influenced by many different things, including lifestyle, family history, emotional health, and nutrition/eating habits. Please complete the following questionnaire to the best of your ability to give us an overall view of your general lifestyle and health habits. New Client Nutrition Assessment Form.
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  • GOALS AND READINESS ASSESSMENT

  • if I could change three things about my health and nutritional habits, they would be....
  • On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the following:
    To improve your health, how ready/willing are you to...
    • Significantly modify your diet
    • Take nutritional supplements each day
    • Keep a record of everything you eat each day
    • Modify your lifestyle (ex: work demands, sleep habits, physical activity)
    • Practice relaxation techniques
    • Engage in regular exercise/physical activity
    • Have periodic lab tests to assess your progress
    PAST MEDICAL AND SURGICAL HISTORY

    Please indicate whether you or your relatives have been diagnosed with any of the following diseases or symptoms Specify which relative and the date of diagnosis). Relatives include parents, grandparents, siblings. Illness/Disease/Symptom

  • Please complete the following information concerning your family's health history: If Living or if Deceased.

  • MEDICAL SYMPTOMS QUESTIONNAIRE

    Rate each of the following symptoms based upon your typical health profile for the past 30 days. If you have been having recent or somewhat severe health symptoms, please indicate that you will fill out the questionnaire for the past 48 hours.

    Past 30 days Past 48 hours

    Point Scale

    0- Never or almost never have the symptom 1 - Occasionally have it, the effect is not severe 2-Occasionally have it, the effect is severe

    3-Frequently have it, the effect is not severe

    4-Frequently have it, the effect is severe

  • MEDICATION, SUPPLEMENT, AND ANTIBIOTIC INTAKE:

    Please provide the names of medications, supplements, and/or antibiotics that you are currently taking:

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  • 1200 / Mg. / Daily. 08/12/2007 current

  • Physical Activity: Using the table, please describe your physical activity.

  • Indicate daily stressors and rate the level of stress from 1 (extremely low) to 10 (extremely high):

  • Please indicate how often you experience the following symptoms:
  • DIET HISTORY
    Do you follow any special diet or have diet restrictions or limitations for any reason (health, cultural, religious or other)?
  • Please indicate the materials you use for cooking and food storage:
  • INTAKE INFORMATION:
    IIf you follow a special diet/nutritional program, check the following that apply:
  • Which meais do you eat regularly, check all that apply:
  • Beverage Intake: Please indicate the beverages you drink, and how often you drink them. Fill in the "Daily Amount", "Weekly Amount", and/or "Monthly Amount"
  • Food Intake: Please indicate the frequency that you eat the following:
  • Eating Style:
    Based on how you eat on a regular basis, please check all that apply:
  • the Client, have been informed, understand and am aware that strength, flexibility and aerobic exercise, including the use of equipment are potentially hazardous activities. I also have been informed, understand and am aware that fitness activities involve a risk of injury and that I am voluntarily participating in these activities and using equipment with full knowledge, understanding and appreciations of the dangers involved. I understand that precautions will be used during this evaluation/training program to prevent physical injury to me.
  • However, in the event of physical injury resulting from the fitness evaluation procedures, equipment usage or training protocols, no medical treatment or monetary compensation will be provided by Whole-Listic Retreats. I assume the full risk associated with the participation in the training programs and agree to hold harmless High Performance Athletic Training Center and all employees associated with this company. I acknowledge that Whole-listic Retreats is relying solely on information provided by me regarding my medical history and physical condition, in allowing me to participate in any evaluation or training session.

    I certify that I have made a complete disclosure of my medical history and physical condition, and that the information provided is true and correct. I certify that I have made a complete disclosure of my medical history and physical condition, and that the information provided is true and correct.
  • the Client, understand that individual session cancellations are to be made at least 24 hours in advance of session request, failure to do so will result in the cancellation of that session, and that I will be charged for the session. I understand that arriving 15 minutes or more later for a session will also result in cancellation of the session and I will be charged for the session. Extensions on packages will not be given due to infrequent use or cancellation of sessions.

    REFUNDS: In the event that a medical problem or prolonged circumstances prevents completion of the contracted sessions within the time period set forth in this agreement, the Client may take an extended period of time to complete sessions. Length of extension will be determined upon presentation of medical documentation.
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  • I hereby understand and agree to the terms and conditions of this contract.
Donna has captivated many individuals over the years as a Speaker | Inner Healing Coach | Facilitator. Her healing gifts and lessons of how to live a holistic life of vitality have been positively received and implemented by many clients over the years.
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