Health Form

• High blood pressure
• Heart disease
• Diabetes or prediabetes
• Obesity
• High cholesterol
• Autoimmune disorder
• Digestive issues (e.g., IBS, GERD)
• Thyroid disorder
• Asthma or allergies
• Arthritis
• Depression or anxiety
• Insomnia or sleep disturbances
• Recent surgery (past 12 months)
• Frequent infections
• Chronic fatigue
• Other

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No

• Low
• Moderate
• High

• Yes
• No

• Yes
• No

• Regularly
• Occasionally
• Rarely

I certify that the information provided is accurate and complete to the best of my knowledge. I understand that this consultation is not a substitute for professional medical diagnosis or treatment. I acknowledge that all program recommendations are intended to support the body’s natural healing processes. I voluntarily assume full responsibility for my participation and release Wellness Secrets and its staff from any liability.

I, hereby release and hold harmless Wellness Secrets, including its affiliates, directors, officers, and agents, from any and all claims, liabilities, damages, or causes of action arising directly or indirectly from my participation in any program, consultation or the use of any equipment, whether on or off the premises.