Health questionnaire and Terms
all info remains private and will not be shared with anyone.
December 2013 marks 10 years ago that I broke my back in four places and spent Christmas in the hospital. More importantly, over the past 15 years, I've gone from 199 pounds, addicted to junk food and suffering so much inflammation I couldn't take my own socks off ... to getting a degree in holistic medicine, going vegetarian, raw vegan, juice cleansing over 300 days, practicing yoga, hiking, meditating, walking around over 60 pounds lighter, and living life to the fullest.
All that I have come to learn, both in my personal journey with holistic health, from my hundreds of clients' journeys, and from my education in holistic medicine, I share with you in my new 6-week Restoring Wellness program.
While there are many healing benefits to the holistic healing modalities I will share with you in this program, I do not claim to provide any 'cures,' nor can I make any recommendations to stop any prescription medications. You alone are responsible for your choices during this program. As a Holistic Health Practitioner and Nutritional Coach, I will educate, coach and motivate you during this program but I'm not qualified; nor do I intend, to medically monitor your progress.
We will tailor your individual needs using holistic healing methods including herbs, aromatherapy, homeopathy and nutrition; however, it is up to you to review this with your Primary Care Practitioner if you wish to solely use holistic, rather than allopathic (or prescription) methods, as I cannot advise you to stop taking prescriptions. With the education and resources l provide during this program as tools, I encourage you to obtain the support of your friends, family and Primary Care Practitioner to assure you receive the best results possible.
All content within this program may not be reproduced for profit, but I do encourage you to save materials throughout the program (directions on how to save within the program) for your binder for future reference. By enrolling in this program, you agree not to share the password with others as this is intended to be a personalized and private "members only" program, which enables me to offer one-on-one support through this Restoring Wellness journey together. By completed this questionnaire, you agree that All Rights Reserved to Stephanie Austin and Contributors and will not reproduce the material beyond your personal workbook.
In joining this program, you agree to these terms and recognize that you act under your own accord and free will to join this program.
Indicates required field
I AGREE TO THE TERMS AS DESCRIBED ABOVE.
Phone Number (SKIP IF INTERNATIONAL)
WHAT IS YOUR AGE?
Prefer not to say but I am over 18
ARE YOU WILLING TO INVITE CHANGE INTO YOUR LIFESTYLE SO AS TO IMPROVE YOUR MENTAL, EMOTIONAL, SPIRITUAL, PHYSICAL, AND ENVIRONMENTAL HEALTH
DO YOU HAVE ANY SPECIAL NEEDS TO BE CONSIDERED THAT MAY REQUIRE ADDITIONAL SUPPORT DURING THIS PROGRAM?
IF YES, PLEASE DESCRIBE
MAJOR LIFE CHANGES IN THE PAST YEAR (NEW JOB, BABY, LOSS, RETIREMENT, DIVORCE, ETC)?
OVERALL HEALTH CONDITION
DESCRIBE YOUR STRESS LEVEL
ARE YOU A VEGETARIAN OR VEGAN?
IN WHICH CATEGORY IS YOUR FAVORITE FOOD?
Carbohydrates (veggies, breads, sweets, pasta, potatoes)
Dairy (cheese, yogurt, ice cream, milk)
Rich, Spicy, Fatty
WHICH OF THE SAME FOODS GIVE YOU THE MOST PROBLEMS (IE. DIGESTIVE UPSET, BLOATING, GAS, BURPING, ETC)?
Rich, Spicy, Fatty
HOW MANY BOWEL MOVEMENTS DO YOU AVERAGE EACH DAY?
WHAT IS YOUR PRIMARY REASON FOR JOINING THIS PROGRAM (SUCH AS: ACUTE/CHRONIC HEALTHCARE SUPPORT, WEIGHT MANAGEMENT, NUTRITIONAL GUIDANCE, ETC)
IF ONE OF YOUR REASONS FOR JOINING IS HEALTHCARE SUPPORT FOR ACUTE/CHRONIC HEALTH CONCERNS, PLEASE DESCRIBE YOUR CURRENT TREATMENT FOR SAID AILMENTS
ADDITIONAL COMMENTS OR QUESTIONS FOR COACH STEPHANIE?
ENTER THE TRANSACTION ID LOCATED AT THE TOP RIGHT, UNDER THE DATE, OF YOUR PAYPAL RECEIPT, WHICH YOU WOULD HAVE RECEIVED AFTER PAYING FOR THE PROGRAM.
How did you hear of this program (person, business, flyer location, etc)? (if a person, please list their first and last name)
If you are enrolled in this program with a family member (using the
Add-On option at 50% off
), please provide their name and email below. If you initially paid under your name using one credit card, I may not have their email address yet, so this provides me with the information to send them their own program emails.
f you haven't enrolled with a family member but want to, click that link above to do so. It will open in a new window where you can sign them up. Then you can come back to this questionnaire.
If you are enrolled on your own, skip the two questions below.
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Phone: 805-996-0279 | Fax: 805-856-1563
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