STB Health & Wellness Assessment Form      
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Email *
Today's Date *
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First and Last Name *
Country *
State *
Cell Phone *
Home Phone
Best time to call? *
How did you find us? *
Birthday *
MM
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DD
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YYYY
Martial Status
Clear selection
Height *
Current Weight  *
Your "Healthy Weight"  *
Blood Type (helps determine diet type best suited for you)
Please Check Current Health Issues and/or Physical Conditions -  You're doing great!  *
Required
Please list physical and/or mental health issues not listed above.  *
If you're on medication do you have a strong desire to get off of them?  *
Required
Allergies & Sensitivities: *
Please select one answer from the drop-down list
Daily Water Intake  *
Organic Food *
Raw Fruits & Vegetables? *
Use a Subscription Meal Delivery Service? If so which one? *
Refined Sugar/Sweets *
Fast Food *
Green Juice & Smoothies *
Smoking *
Alcohol Intake *
Fasting *
Spiritual Morning Routine *
Tithe *
Time with Nature *
Relaxing Baths *
Please select one answer from the drop down list
Please select one answer from the drop down list
Daily Bowel Movement
Clear selection
Enemas *
Please select one answer from the drop down list
Colonics
Please select one answer for each question below
Detoxing
Holding any unforgiveness?  
Haunted by some emotional trauma? 
Do you know your purpose (calling)?  
Are you living your life's purpose (calling)? 
Please select one answer from the drop down list
How much support are your family and friends giving you towards your diet and lifestyle goals? *
Please select one answer for each question below
Please list 3 specific URGENT NEEDS you would like to see manifest in your life within the next 12 to 24 months.  *
What do you think you need to obtain these urgent needs?  *
Would you find the financial resources to invest in these changes if you knew by doing so you'd reach your goals? *
Required
Do you have any family or friends that would like support?   *
Required
Would you be interested in becoming a Certified Detox Coach?   *
Required
A copy of your responses will be emailed to the address you provided.
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