check

Health and Wellness Journey Application

Health and Wellness is the newest buzz word nowadays. With the recent pandemic Health has become the main concern for EVERYONE AROUND THE WORLD.

This application, will allow us to assess your needs to make sure that our Health and Wellness program is a great fit for you. If we find that you are a great fit, you will receive notification to proceed to the next step. 

To your Health!!

 

Click the button below to start.

Start

Question 1 of 56

Full Name

Question 2 of 56

Email Address

Question 3 of 56

Best Phone Number

Question 4 of 56

Occupation

Question 5 of 56

How did you find me?

Question 6 of 56

What made you reach out to me?

Question 7 of 56

Who is your Primary Physician?

Question 8 of 56

When was your last exam?

Spiritual Health Coaching

Let's look at coaching.

Question 10 of 56

Have you ever used a coach before? If so who, why and what were the results? 

Question 11 of 56

What are your biggest Health Concerns right now?

Question 12 of 56

How does this health concern effect your quality of life?

Question 13 of 56

What have you done to reduce symptoms or eliminate the issue?

Question 14 of 56

What Health issues are you currently being treated for by a physician?

Question 15 of 56

What is motivating you to change today?

Question 16 of 56

Describe what your health would look like if you were at your best health?

Question 17 of 56

Where would you like to see yourself in 30, 60 or 90 days?

Question 18 of 56

How much are you willing to invest in yourself to achieve that goal?

A

$1500.00

B

$1,500.00 - $2,500.00

C

$2,500.00 - $3,500.00

D

$3,500.00 - $5,500.00

E

$5,500.00 - $7,500.00

Question 19 of 56

If you continue in your present state of health , what will your health look like in 6 months, 1 year, or 5 years down the road? 

Menstrual Cycle

Tell me about the history of your cycle

Question 21 of 56

When was your last menstrual cycle?

Question 22 of 56

How old were you when you had your first period?

Question 23 of 56

How long (days) is your typical cycle? 
How is the Flow? (Heavy/Light Clotting/Bleeding in between periods)

Question 24 of 56

Please describe your moon cycle over the last 3 months and historically. (Heavy, light, irregular, days on, 28 days, more or less)

Question 25 of 56

Do you suffer from pre-menstrual symptoms/ PMS? 

A

yes

B

no

Question 26 of 56

If you suffer from PMS, which symptoms to you usually have? (Select all that apply)

A

Headache

B

Pain/Cramping

C

Mood Swings/Irritability

D

Cravings

E

Bloating/Water Retention

F

Breast Tenderness

Question 27 of 56

Are you pregnant?

A

yes

B

no

Question 28 of 56

When was your last pap test?

 

Question 29 of 56

Have you ever had a hysterectomy?   If Yes, What type?

Question 30 of 56

Have you ever used birth control? if yes, What type?

Question 31 of 56

Please indicate if any of the following applies to you 

 

  ​

 

 

 

A

Vaginal Discharge 

B

Abnormal pap tests 

C

 Pain during intercourse 

D

​Low libido 

E

Vaginal Itching 

F

Vaginal dryness 

G

 ​Vaginal Odor 

Breast Health

Breast History

Question 33 of 56

Do you preform monthly self breast exams?

 

A

yes

B

no

Question 34 of 56

When was your last breast exam?

Question 35 of 56

When was your last mammogram?

 

Question 36 of 56

Do you have any history of breast changes?

Question 37 of 56

Have you in the past, or are you currently being seen by a therapist?

If so, what was your diagnosis?

Personal History

Please answer the following questions as they relate to your past experiences. Please be very descriptive. ​Answering these questions will assist me in preparation for our discovery session. These questions sometimes stir up old emotions; if so please include these emotions in your answers.

Question 39 of 56

Birthdate, City and State, Time

 

Question 40 of 56

What have you been told about your birth story?

Question 41 of 56

What is your birth order (only child, oldest, middle child, youngest)

Question 42 of 56

How is your relationship with your mother?

 

Question 43 of 56

How is your relationship with your maternal grandmother?

Question 44 of 56

How is your relationship with your maternal grandfather?

Question 45 of 56

How is your mother's relationship with your maternal grandmother?

Question 46 of 56

How is your mother's relationship with your maternal grandfather?

Question 47 of 56

How is your relationship with your father?

Question 48 of 56

How is your relationship with your paternal Grandmother?

Question 49 of 56

How is your relationship with your paternal Grandfather?

Question 50 of 56

How is your Father's relationship with your paternal Grandmother?

Question 51 of 56

How is your Father's relationship with your paternal Grandfather?

Question 52 of 56

What is your Favorite color? 

Question 53 of 56

What is your favorite food? 

Question 54 of 56

How old were you when you lost your virginity. Was the experience healthy? Please describe. 

Question 55 of 56

Do you have any history of molestation? If so, Please describe.

Question 56 of 56

What additional Health or Life concerns do you have right now that we should also consider?

Confirm and Submit