Health Discovery Consultation

Health Discovery

Consultation Form
Name*

First NameLast Name
Phone*
Address*

Street Address

Street Address Line 2

City / SuburbState / Province

Postal / Zip Code
Email *
Occupation*
Date of Birth*
Month / Day / Year
How did you hear about Cleanse Theory Kitchen? Sarah Ellen Wellness Coaching?*
Main problem(s)you would like us to help you with*
How long ago did this become a problem for you?*
Have you been given a diagnosis for this problem, if so by whom?*
What kinds of treatments have you tried?*
Have you participated in a cleansing/detox program? If yes; please specify*
Digestive System Health
How much water do you drink? (Litres / Oz)*
Weight (kg / lbs)*
Do you eat/drink any of the following*

Red MeatWhite MeatFishDairyBreadWheatYeastSugarFruitVegetablesAlcoholCarbonated drinksEggsNutsCoffee
What types of things have you had for BREAKFAST over the past 30-60 days?*
What types of things have you had for LUNCH over the past 30-60 days?*
What types of things have you had for DINNER over the past 30-60 days?*
What kinds of SNACKS do you eat and what TIME of day do you eat them?*
What time do you eat your first meal for the day?*

Hour Minutes

AM/PM Option
What time do you eat your LAST meal/snack for the day?*

Hour Minutes

AM/PM Option
Do you take supplements, Probiotics or Naturopathic Herbs? Please Specify*
How frequent are your bowel movements*

Irregular1 per day2-3 per day1 per week2-3 per week4 per week
Are your bowel movements painful or difficult?*
Have you had a Colon Hydrotherapy treatment before?*
SELECT current or past conditions*

AllergiesAbdominal ProblemsAnxietyArthritisAsthmaCirculatory ProblemsDepressionCancer of the colonDiabetesDigestive ProblemsStressProlapsed ColonBack AcheHearing ProblemsStrokeProsthesis or DenturesHeadachesHeart ProblemsHistory of SeizuresLow Blood PressureMigraine HeadachesGall Bladder ProblemsIrritable Bowel SyndromeAccident/TraumaHigh Blood PressureKidney ProblemsTumorsChronic FatigueCandidaChronic PainMenstrual Pain /ProblemsCirrhosis of the LiverMuscle/Bone InjuriesSkin ProblemsFlatulenceMuscle/Joint PainVisual ProblemsPhlebitisNumbness/TinglingWeight ProblemsRash/Athletes Foot/TineaParasitesPCOS / Ovary concernsHair LossAuto ImmuneOther
Please list any health conditions in your family - especially your Parents & Grandparents
Select ANY of the following that apply to you*

Mercury/Metal Dental FillingsBladder InfectionBloatingBlood in stoolBurning/Itching anusConstipationContraceptiveDiarrhoeaHaemorrhoidsRectal BleedingRecent Barium EnemaRecent ColonoscopyBowel StrainVomitingOther
Select ANY of the following that apply to you*

Abdominal HerniaAbdominal SurgeryAbdominal DistensionAcute Liver FailureAnal Fissures & FistulasAnemiaAneurysmCancer of the colonColitis Active or BleedingCrohns DiseaseCardiac ConditionsDiverticulosos/DiverticulitisHaemorrhoidectomy SurgeryHemorroids (Severe or Bleeding)High Blood PressureIntestinal PerforationsKidney DialysisLupusPregnantRectal/Colon surgeryRectal BleedingRenal InsufficienciesSteroid MedicationsNone
Please list any medications you currently take or have taken in the past 6 months
General Health
Do you have regular sleep patterns?*
Do you have any infectious diseases?*
Please list any traumatic life events
(divorce, bankruptcy, death, loss etc)
Do you smoke? How many per day?*
Do/Have you taken recreational drugs?*
Do you exercise*

Never1 day per week2-3 days per week4-5 days per week7+ days per week1-2 days per month
Height*
Emergency Contacts
Emergency Contact Name
Emergency Contact Phone
Doctors Name
Doctors Phone
Health & Wellness Goals
Please list your 3 health & wellness goals*
Terms and Conditions
Accept Terms

I confirm that the information above is correct and that to my knowledge I have not withheld any information that may be relevant to my consultation. By ticking this box I acknowledge that wellness coaching & or any holistic treatments provided by Sarah Ellen and her team are not intended to replace the relationship with my primary health care providers. My consultation with a Wellness Coach is not intended as medical advice. I will not hold Sarah Ellen / my coach responsible for any affects within my body after any wellness session. I understand that the services, packages and product purchases if I choose to purchase them are not refundable. I affirm that I have notified my coach of all known medical conditions, medications and injuries. I agree to inform my coach of any changes in my health and medical condition. I understand that there shall be no liability on the coach’s part should I forget to do so. By signing this release, I hereby waive and release my coach from any and all liability, past, present, and future relating to wellness coaching, detox, and cleansing protocols.
Please list any foods, fruits, vegetables, spices or flavors you do not like and will not eat.*
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Health Discovery

Digestive System Health

General Health

Emergency Contacts

Health & Wellness Goals

Terms and Conditions