Schedule a Consultation - Wellness Secrets

Participant Information

Full Name

Date of Birth

Telephone No.

Email

Address

Occupation

Marital Status

Emergency Contact

Name

Relationship

Phone

Health History

If other, please specify

Medications & Supplements

Please list all current medications and supplements including dosage and frequency:

Diet & Lifestyle Habits

Describe your current diet (include common meals, frequency, etc.):

How many glasses of water do you drink per day?

How many hours of sleep do you get per night?

Do you smoke?

Yes
No

Do you consume caffeine?

Yes
No

Do you drink alcohol?

Yes
No

Do you exercise regularly?

Yes
No

If yes, what type and how often?

Do you have any food allergies or sensitivities?

Yes
No

If yes, please specify:

Mental, Emotional & Spiritual Health

How would you describe your stress level?

Low
Moderate
High

How do you usually manage stress?

Do you struggle with depression, anxiety, or mood swings?

Yes
No

Are you currently seeing a counselor or therapist?

Yes
No

Do you spend time in personal prayer or Bible study?

Regularly
Occasionally
Rarely

Health Goals

Please list your top 3 health goals:

Signature & Consent

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.

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