Nature-Restores.com

Nature-Restores.com Health Assessment Form

Start

IMPORTANT: This is a health and nutrition evaluation is intended for educational purposes only, to assist the individual in learning how to preserve their own health. It is advisable to consult with your personal health care provider before Implementing any lifestyle changes.

This form is the initial Health Assessment form and this form will help us to understand more fully about your health needs.  Please answer all questions in the Health Assessment form.  We advise that you tell us of any existing or pre-existing health conditions that you have.
The Nature-Restores Health Assessment is a service with a fee of £50 which is paid at the beginning.  A further consultation is a fee of £30 per hour.  Whatever natural remedies which are advised to be used can be purchased by you or by Nature-Restores where is and additional charge.

Health Assessment Form
Name
Name

Telephone

List any health concerns you have: (physical, mental, social or spiritual):

Are you currently being treated for any ailments?

Please list any surgery that you have had (along with the date):

Add Remove

What diseases have you been diagnosed with? (please list all)

Add Remove
Are you presently experiencing any of the following: (please select all that apply)
Do you suffer from any of the following emotional/mental disorders: (please select all that apply)
Sex
Blood Pressure
/

Pure Air

Do you open the windows in your home to have pure air circulated?
Do you sleep with your bedroom window slightly open?
Do you have plants in your home?
Do you keep rubbish bags with rotten fruit or vegetables in your home?

Sunlight

Do you exercise or go for walks during the hours of 9:00am - 3:00pm?
Do you use Vitamin D3 liquid supplement?