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 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*
Please list any foods, fruits, vegetables, spices or flavors you do not like and will not eat.*
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.
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Health Discovery

Digestive System Health

General Health

Emergency Contacts

Health & Wellness Goals

Terms and Conditions