Heart Rock Healing – In-Depth Client Consultation Form

  • Heart Rock Healing – In-Depth Client Consultation Form
  • LIFESTYLE CHECK-IN
  • DISCLAIMER & INFORMED CONSENT
CLIENT INFORMATION
Preferred Contact Method
MAIN HEALTH CONCERNS
Have you received a diagnosis for any of them?
MEDICAL HISTORY
Do you currently have any diagnosed health conditions?
Any major illnesses, surgeries, or hospitalizations in the past?
Family history of chronic illness?
MEDICATIONS & SUPPLEMENTS
Do you take over-the-counter meds or supplements?
Do you currently take any herbal remedies or teas?
Sleep
How many hours of sleep do you get per night?
How would you describe your sleep? (Check all that apply)
Stress Level
What's your stress level?
Symptoms of stress you experience:
Digestion & Elimination
Bowel movements
Digestive issues (check all that apply)
Movement & Exercise
Do you exercise regularly?
Outdoor Time
How often are you outside?
Spiritual Practices
Do you believe in a higher power or spiritual connection?
Do you use any spiritual or mindfulness practices? (Check all that apply)
Water Intake
How much water do you drink per day?
Diet
Diet (Check all that apply)
Toxin Exposure (Check all that apply):
WELLNESS GOALS & EXPECTATIONS
What are your health goals for working together? (Check any that apply):
Are you open to dietary or lifestyle changes?
Have you worked with a natural health practitioner before?
DISCLAIMER & INFORMED CONSENT
I understand that Deb Lewis, Certified Herbalist and Holistic Health Coach, is not a licensed medical doctor and does not diagnose, treat, or cure disease. All recommendations are educational in nature and intended to support the body’s natural ability to heal. I understand and acknowledge:

-That I am encouraged to consult with my primary care physician before starting any new holistic program.

-That all herb-medication interaction suggestions provided are based on Deb’s best research from trusted sources, but due to the changing nature of pharmaceuticals and product names, complete accuracy cannot be guaranteed.

-That it is my responsibility to disclose all medications, supplements, and health conditions truthfully.

-That any herbs, teas, or tinctures recommended are offered as a complement to, not a replacement for, professional medical care.
Do you agree to this disclaimer and informed concent?