Whole-istic Health Consultation

All Information Is Kept Confidential.                                                                                               

Please set aside 20–30 minutes to complete this form in one sitting -- There is no Save & Return option. The time attention and effort put into this form is your first investment in Yourself -- and we take that seriously.

The questions are detailed on purpose. They allow us to take a Whole-istic approach—looking beyond symptoms to understand your environment habits history and patterns. This is how we meet you exactly where you are and can guide you to being more proactive and restoratively empowered on your health-wellness journey.

Our approach is clear practical and easy to put into action -- and built for people who want real support real structure and real results – sustained over time -- not a temporary fix.

If you’re serious about progress and real healing -- this process supports you. If not this will likely feel like a lot — and that’s fine too. Take your time and answer honestly. The quality of your responses directly impacts the quality of your results.                                                              

Complete This Form Before Exiting -- There is No Save & Return Option

Email *
Please Enter Today's Date *
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Email Address *
Full Name *
Street Address  *
Phone Number  *
Birth Mo Day & Yr *
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Birth City - State - Time (if known)  *
Height & Weight *
Preferred Method of Communication
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How did you hear about SXC HEALTH? *
HEALTH PRIORITY & GOAL SETTING  

This is where some people falter. If you know exactly what you want --You move like someone refusing to fail. If your reason is real discipline becomes automatic. When you claim your goals without apology everything shifts in your favor. Stop over-thinking – Start choosing – Your future is built by action not hesitation.

 12. Why is it a priority for you to invest in your health right now? 

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13. List your Top 3 Health Goals *
14. Looking Forward One Year:  you have achieved your health goals—what is different physically, mentally, spiritually?       *
15. What will happen if you do NOT reach your health goals?  *
16. What are the main reasons you believe your health has declined or plateaued? *
MEDICAL HISTORY

Western medicine names conditions — We look for the causal patterns beneath the symptoms. List everything you’ve ever been told, diagnosed with or treated for. Even if it seems unrelated include it — it’s all connected.

17. Blood Type *
18. Blood Type RH Factor *
19. List any Diagnosed Medical Conditions & approximate Month & Year *
20. Surgeries? (year & details) *
21. Hospitalizations? (year & details) *
22. List all medications Prescription & OTC: name, strength, frequency, purpose (Ex. aspirin-baby-daily-thin blood) *
FAMILY HEALTH HISTORY

Your body didn’t start with you. This helps us see inherited patterns and tendencies. Fill in what you know — don’t guess

23. Mother -- Age & Health Conditions *
24. Father's Age & Health Conditions  *
25. Siblings Age & Gender - Health Conditions *
26. Maternal Grandmother — Age & Health History *
27. Maternal Grandfather -- Age & Health History *
28. Paternal Grandmother -- Age & Health History *
29.  Paternal Grandfather -- Age & Health History *
LIFESTYLE & DIETARY HABITS

This section tells the truth — whether you realize it or not. Most health issues are tied to daily habits. Be honest about what you actually do not what you should be doing.

30. Exercise *
Required
31. What type of activities/exercise/movement do you do? *
32. Do you smoke? 
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Required
33. Do you drink Alcohol? If so how often & how many years
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34. Describe your Diet (Red Meat, Seafood, Diary, Fruits, Starches, Vegan, Vegetarian, Pescatarian, Paleo, Keto, Gluten Free) etc. * *
35. Foods consumed regularly (Select all that apply)
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Required
36. List any FOOD ALLERGIES? *
 37. What COOKING OIL do you use, if any? *
38.  How many Meals do you have daily?
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Required
39. How many snacks do you have daily?
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Required
40. Approximately how many bottles of water do you drink daily? (1 bottle = 16oz) *
Required
GENERAL HEALTH PROBLEMS

Don’t minimize things here. If it happens even occasionally mark it. Small symptoms are usually early signals not random events.

41. Please indicate any symptom you sometimes experience. (Cardiovascular) *
Required
42. Frequency of Cardiovascular Symptoms
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Required
43. MUSCLE & JOINT Symptoms — check all that apply *
Required
44. How frequent (if at all) are Muscle & Joint symptoms?
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Required
45. EENT Symptoms — (Eyes, Ears, Nose, Throat) Check all that apply         
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Required
46.  Frequency of EENT Symptoms? *
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Required
47.  KIDNEY/URINARY Symptoms — check all that apply
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Required
48. Frequency of KIDNEY/URINARY Symptoms
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Required

49. GASTROINTESTINAL symptoms — check all that apply

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Required
50. Frequency of GASTROINTESTINAL Symptoms
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Required

51. PSYCHOLOGICAL/NEUROLOGICAL Symptoms  Check all that apply

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Required
52. Frequency of PSYCHOLOGICAL/
NEUROLOGICAL Symptoms
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Required

53. GENERAL/ENERGY— check all that apply

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Required
54. Frequency of GENERAL/ENERGY Symptoms  *
Required
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