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Laya Wellness Assessment
We believe that there is no one thing that makes a person either healthy or ill... we aim to produce wellness holistically. Holistic wellness is a means of living a healthy lifestyle that includes looking at the body as an entire system, and addressing its needs as a whole to prevent and in some cases balance dis-eases.
Our Assessment has changed a bit. We now use this assessment to create a Personalized Natural Supplement Plan. Based on your submission, we will choose your daily plan (in some cases you may require A.M. and P.M. supplements) and package in single servings. please choose all that apply and use the extra space to elaborate is necessary.
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* Indicates required question
Email
*
Your email
If referred by an Organization, please choose which one.
Uzazi Village
Heroic Healers
Clear selection
Name
*
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Address
*
Your answer
Phone Number
*
Your answer
Emergency Contact
*
Your answer
Do you have a Health & Wellness account through your job?
*
Flexible Spending Account (FSA)
Health Savings Account (HSA)
No
Symptom Check
Check any chronic symptoms that you may have. Elaborate if you need to and check any specific areas where necessary.
Abdominal Pain, Cramping
*
No
Yes
If yes, choose one of the following.
Choose
Across the abdomen
Around the navel
Lower left side
Lower right side
Upper left side
Upper right side of rib cage
Any location
NONE OF THESE
Anal bleeding, itching, pain, swelling
*
No
Yes
Other:
Back Pain
*
Yes.
No.
Bad Breath
*
Yes
No
Sometimes
Bleeding, menstrual, heavy or irregular
*
Yes
No
Blinking, frequent
*
Yes
No
Bloating
*
Yes
No
Blood in sputum, vomit, urine, stools, or from vagina or penis
*
Yes
No
Body Aches
*
Yes
No
If yes, explain
Your answer
Body odor
*
Yes
No
Breast lumps
*
Yes
No
If yes, explain
Your answer
Breast tenderness
*
Yes
No
Sometimes
Shortness of breath
*
Yes
No
Sometimes
Bruising, easy
*
Yes
No
Chest pain
*
Yes
No
Chills
*
Yes
No
Cold sweats
*
Yes
No
Cough, persistent
*
Yes
No
Delirium
*
yes
No
Disorientation
*
Yes
No
Dizziness, light-headed
*
Yes
No
Maybe
Double vision
*
Yes
No
Drooling
*
Yes
No
Drowsiness
*
Yes
No
Dry Mouth
*
Yes
No
Eye problems
*
Bulging
Drooping
None
Fever
*
Yes
No
Gas, burping or other (explain either)
*
Your answer
Hands and/or feet, cold
*
Yes
No
Headaches
*
Mild, not often
1
2
3
4
5
Severe, quite often
Heartbeat, irregular or rapid
*
Yes
No
Hot sweats, then chills
*
Yes
No
Incontinence (urinary)
*
Yes
No
Maybe
Required
Intercourse, painful
*
Yes
No
Required
Irritability, mood swings
*
Sometimes, it depends
1
2
3
4
5
Often, very noticeable
Joint pain, swelling
*
Yes
No
Leg pain
*
Yes
No
Lymph nodes, swollen
*
Yes
No
Mouth sores
*
Yes
No
Muscles
*
Fine, strong
loss of control
cramps
pain, weakness
all of the above
Nausea
*
Yes
No
If yes, explain
Your answer
Neck pain, stiffness
*
No stiffness
1
2
3
4
5
Very stiff
Night sweats
*
Yes
No
Numbness
*
Yes
No
Pulse, weak
Your answer
Seizure
*
Yes
No
Swallowing, difficulty
*
Fine
1
2
3
4
5
Hard to swallow
Sweating, excessive with no activity
*
I never sweat
1
2
3
4
5
I'm always sweating
Swelling
*
None
Ankles or Feet
Hands
Legs
Abdomen
Thirst, excessive
*
Yes
No
Tremors
*
Yes
No
Urination, frequent
*
yes
No
Vaginal discharge, itching
*
Yes
No
Does Not Apply
Weight gain
Your answer
Weight loss
Your answer
Wheezing
*
Yes
No
HOW'S YOUR ENERGY
Do you feel like you have too much energy, just enough energy, or low energy?
*
High energy
Medium energy
Low energy
Required
Do you often feel tired?
*
Yes
No
Do you often feel so wound up you cannot settle down i.e. fidgety, mind always going, pacing, feeling like you need to do something?
*
Yes
No
Maybe
Do you feel like you have enough energy each day to accomplish everything you want to do?
*
Yes
No
Maybe
How often do you exercise or engage in any physical activity?
*
Daily
4-6 Days per week
1-3 Days per week
rarely
I can't exercise due to medical issues
What type of job do you have?
*
Desk, sedentary
Active, but stressful
Just stressful in all ways
Neither
Are there certain situations, people, or places that you feel like they drain you? For example, you feel fine before you interact, but feel drained afterward?
Yes
No
Sometimes
Clear selection
SELF CARE
Explain your idea of self care.
*
Your answer
Do you use your vacation and personal days at work to go on a vacation or take a break or do you use most of your vacation days because you are not feeling well?
*
I take a break or vacation.
I'm just not feeling well.
There's a mixture of this.
If you sometimes vacation and sometimes take sick days... how do you feel on vacation?
Your answer
Do you take breaks to do something nice for yourself on a regular basis or do you tend to take breaks when you cannot avoid them anymore?
*
Yes
No
Do you feel like you don’t have enough time to do something special for yourself?
*
Yes
No
Sometimes
Do you often put the needs of others before your own?
*
Yes
No
Sometimes
When was your last extended break or vacation?
*
MM
/
DD
/
YYYY
#GOALS
Do you end the week feeling like you have accomplished your goals?
*
Yes
No
Do you feel like you need more time to accomplish your goals each week?
*
Yes
No
Are you happy with your life, self, and the trajectory your life is going in?
Yes
No
Clear selection
If no, what do you wish was better about your life?
Your answer
Do you often end the year and realize that you did not meet a goal such as losing weight or other self-improvement goals?
*
Yes
No
Do you feel stuck or like you cannot resolve a particular issue you deal with each year?
*
Yes
No
THE SNOOZE
How many hours do you typically sleep at night without waking up (please do not include instances of unusual outside interference such as baby crying, sudden noises, etc)?
*
Choose
1-3 hours
3-5 hours
5-7 hours
7-10 hours
If you sleep more than 3 hours at a time but still wake up more than once during the night, is it due to noises or other interference?
Noise usually.
I have anxiety or fear about something usually.
I just can't sleep through the night.
Clear selection
When you wake up in the morning do you feel well rested, relaxed, refreshed, and ready to start your day or do you feel like you need coffee or more sleep?
*
Yes
No
Do you feel like you become irritable or agitated during the day often?
*
Yes
No
Sometimes
Do you often lay awake when you try to sleep because your mind is racing?
*
Yes
No
HEADSPACE
Do you feel like other people generally like you and have a positive outlook about you?
*
Yes
No
Maybe
Do you feel like people have a hard time getting along with you whether it is specific types of relationships like romantic, friendship, coworkers, or in general?
*
Yes
No
Maybe
Do you enjoy spending time alone or do you prefer going out with friends?
*
I like alone time.
I love hanging out.
Do you feel that you need to listen to music or watch TV at all times vs having time alone to sit in silence?
*
Yes
No
Are your thoughts about yourself, life, and others generally positive?
*
Yes
No
LOVE & HAPPINESS
Do you feel energized, happy, and content after spending time with your friends, loved ones, and other close relationships in your life in general?
*
Yes
No
Do you feel energized, happy, and content in general without any outside forces outside of self?
*
Yes
No
Are you currently doing exactly what you want to do in your life right now (dreams, wishes, goals)?
*
Your answer
Do you often wish your life was different?
*
Yes
No
Do you feel like amazing things happen in your life on a weekly basis?
*
Yes
No
Sometimes
Do you feel like your life is getting better with time, do you feel positive about your future?
*
Yes
No
HISTORY
What medical concerns have you had or do you have at this time?
*
Your answer
Indicate if you have blood relatives with any of the following:
*
Cancer
Diabetes
Heart Disease
High Colesterol
High Blood Pressure
Osteoporosis
Thyroid Disorder
None
Required
Do you have any complaints about any of the following...
*
Appetite (too low/high)
Bleeding Gums
Bruising
Swallowing or Chewing
Constipation
Diarrhea
Depression
Edema (swelling/fluid retention)
Indigestion
Lethargy/Exhaustion
Menstrual Difficulties
Pain in Abdomen (female organs)
Seeing in dim light
Sudden weight change
Stress or Anxiety
None
Required
Are there any complaints about something not listed above? Diagnosis? If so, what?
Your answer
Do you take any over the counter, prescription drugs, or supplements at this time?
*
Yes
No
If yes, please list them here:
Your answer
Do you use tobacco in any way?
*
Yes
No
Did you recently stop smoking (within a year)?
*
Yes
No
GRUB
List any food allergies or intolerance:
*
Your answer
Do you follow a special dietary plan?
*
Yes
No
If yes please select which one applies.
Vegan
Vegetarian
Low Cholesterol
Pescatarian
Low/High Carb
AIP
Gluten - Free
Dairy - Free
Kosher
Paleo
Ketogenic
Other:
Clear selection
Identify any foods that you particularly like.
*
Your answer
Have you ever followed a special diet?
*
Your answer
Do you have any problem purchasing the foods that you wish to buy?
*
Yes
No
Do you eat at regular times each day?
*
Yes
No
Sometimes
Do you drink alcohol?
*
Yes, rarely.
Yes, regularly
Yes, daily
No
Would you like for us to create a Nutritive Overview based on your chronic conditions?
*
Yes
No
Maybe
What changes would you like to make?
Your answer
Please tell us any other information that you feel is relevant to your overall health.
Your answer
Which of the following do you want more information about?
*
3, 6, or 12 month Wellness Plan (Customized Treatment plan at our Wellness Center in KCMO)
Herbal Medicine & Natural Supplements
Wellness Coaching w/ Yoruba Healer
Elemental Membership
None
Required
Based on the text above, please tell us the amount of structure you believe meets your needs.
Provide a complete Nutritive guide for food and herbs, plus my Personalized Natural Supplement Plan.
I don't want services, I just want to set goals and start a monthly supplement plan.
Set up a plan with regular appointments and monthly herbal supplements. I need to create a budget.
I have a specific goal and I want to do everything it takes to reach it. I don't have a budget.
Thanks!
Thank you for your openness and willingness to share these personal things with us. We look forward to walking with you on this journey of a healthier and happier YOU! If you did not get a confirmation message after tapping 'Submit', it means that there is a *Required question left unanswered. Please make sure to answer all questions in order to receive a personal email from our Herbalist. Please note that this is not an automatic questionnaire. A REAL person will read your submission and give you customized information based on your very unique circumstances! This may take some time.
Send me a copy of my responses.
Submit
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