iHeal Assessment

iHeal Complete Lifestyle Assessment

The completion of this Lifestyle Assessment takes approximately 30 minutes. Data inserted cannot be saved so we recommend that once the filling of the assessment has begun, it should be completed and submitted by pressing the "Submit Assessment" button below.

Disclaimer

iHeal Representatives are NOT doctors, nurses, dieticians, or professional medical care providers unless they happen to also have undergone licensing in those fields. The information shared by iHeal Representatives is provided for general informational purposes only and is not intended to replace medical advice or treatment. iHeal Representatives have no expertise in diagnosing, examining or treating medical conditions, nor can they accurately determine the specific effect of any lifestyle habit on medical conditions.

Agreement

I agree that I will take no action or inaction based solely on a product or suggestions made by the iHeal Representative. I understand that lifestyle changes and/or questions about symptoms, medications, exercise techniques, and my health in general, should be addressed directly to a licensed health care professional. By completing the assessment and participating in the iHeal consultation, I assume all risk of injury, and agree to release and discharge the iHeal company and the iHeal Representatives from any and all claims or causes of action, known or unknown, arising from the interaction with the iHeal representative.

Confidentiality

Once completed, the information contained in this form will be treated with utmost confidentiality. Information will not be released to a third party without your written consent.

CURRENT HEALTH STATUS

* Indicates required field

Name *

First

Last

GENDER *

Male Female

List any health concerns you have: (physical, mental, social and/or spiritual) *

When did you last consult a physician? *

Are you currently being treated for any ailments? *

Yes No

If yes, which ones? *

Please list any surgery that you have had (along with the date) *

What diseases have you been diagnosed with? (please list all) *

What specific condition(s) would you like this consultation to address? *

What is your age? *

If applicable, how long have you been married or divorced? *

Current Weight: (lbs.) *

Blood Sedimentation Rage *

Blood Pressure ( ___ / ___ ) *

Pulse *

Glucose *

Postprandial (2 hours after meal) *

Cholesterol *

HDL *

LDL *

Triglycerides *

Please list all the medicines or pills you are currently taking: *

Please list all supplements and/or herbs that you are taking (vitamins, minerals, nutritional drinks etc...) *

NUTRITION

Do you eat any meat or flesh items (chicken, turkey, pork, shrimp, etc.) ? *

Yes No

Do you eat refined white products (i.e. white bread, white rice, white flour products, etc. ) ? *

Yes No

Do you eat any dairy items or eggs (i.e. milk, cheese, yogurt, chocolate, etc.) ? *

Yes No

Which ones? *

How many servings of fruit per day? *

How many servings of vegetables? *

Do you use condiments (i.e. ketchup, mustard, mayonnaise, barbecue sauces, veggienaise, mayonnaise, salad dressings, pickles, vinegar, etc.) ? *

Yes No

Do you add any of the following spices to your foods: cinnamon, nutmeg, cloves, curry, hot sauces, and cayenne peppers, black and white peppers) ? *

Yes No

Do you eat fried foods? *

Yes No

If so, how often? *

Do you use margarine or butter? *

Yes No

If so, how often? *

Do you use baking powder or baking soda? *

Yes No

Do you eat fresh bread? (bread eaten less than 48 hours after baking) *

Yes No

Do you eat or drink any cocoa, chocolate, or ice cream? *

Yes No

If so, how often? *

Which oils do you cook with? *

Do you read the labels of food items that you buy from the store? *

Yes No

List any sweeteners you consume (i.e. sugar, honey, splenda, sweet & low, equal or additional artificial sweeteners, etc...) *

How much and how often do you eat nuts? *

Which ones? *

Do you eat any canned items? (beans, veggies, fruits, veggie meats etc.) *

Yes No

If so, which ones? *

Are you on any special diet? *

Yes No

If so, please list. *

Do you eat out? *

Yes No

If so, how often? *

Do you use salt? *

Yes No

Does the salt contain iodine? *

Yes No

EXERCISE

Do you exercise? *

Yes No

If you exercise...

How many days per week? *

How many minutes per day? *

How would you rate your exercise? *

What is your favourite type of exercise? *

How do you feel after you exercise? *

Do you experience any pain while you are exercising? *

Yes No

WATER

How many glasses of water do you drink per day? *

What kind of water do you commonly drink? *

Is your water filtered? *

Yes No

At what temperature do you drink your water? *

Do you eat ice? *

Yes No

How many glasses of juice do you drink per day? *

How many cans/bottles of soda do you drink per day? *

What other liquid do you drink ? (i.e. tea, wine, alcohol, beer, soda, milk, vitamin water, etc.) *

Do you drink with your meals? *

Yes No

What colour is your urine normally? *

SUNLIGHT

How much direct sun exposure do you get per day? *

Do you sunbathe? *

Yes No

If so, for how long? *

Do you wear short sleeves? *

Yes No

Do you ever use sun block? *

Yes No

Do you have any abnormal sensitivity to the sun naturally or due to any medications? *

Yes No

Do you take vitamin D supplements? *

Yes No

Do you have any family history of skin cancer? *

Yes No

TEMPERANCE

What is your current occupation? *

Please list your last five jobs/occupations and the applicable years of service. *

Do you smoke/use tobacco products in any form ? (i.e. chewing tobacco) *

Yes No

Did you ever use tobacco products in the past? *

Yes No

If so, how much and for how long? *

Do you use alcohol in any form? *

Yes No

If so, how much and for how long? *

Do you ingest caffeine in any form? (e.i. coffee, teas, mate, colas, energy drinks, etc.) *

Yes No

If so, please list. *

Are you in the habit of overeating? *

Yes No

Do you have the habit of eating too fast? *

Yes No

How many meals per day do you usually have? *

Do you chew your food thoroughly? *

Yes No

Do you snack between meals? (this includes any food items and juice) *

Yes No

List any desserts you eat. (includes candies, cake, pies) *

Do you eat at set meals times? *

Yes No

What time do you eat breakfast? *

What time do you eat lunch? *

What time do you eat supper? *

Would you say that your dress is healthful and modest? *

Yes No

Please list your leisure activities (i.e. watching TV, reading, sports, dancing, board games, etc.) *

How much time do you spend on leisure activities per week? *

Do you tend to overwork? *

Yes No

Please list any addictions *

Have you been involved with substance abuse? *

Yes No

If so, please list. *

Do you read novels, science fiction, pornography, fashion magazines, computer games? *

Yes No

If so, which ones? *

Do you attend cinemas, dances, night clubs, house parties or amusement parks? *

Yes No

If so, which ones? *

Do you play any competitive sports? *

Yes No

If so, which sports? *

Please list the different types of music that you listen to. *

AIR

Where do you live? *

Do you sleep with your windows open? *

Yes No

Do you open your windows/doors daily to air out the home? *

Yes No

Do you live or work in a smoke-filled environment? *

Yes No

Are there any smokers living in your home? *

Yes No

Do you have any live plants throughout your home? *

Yes No

Are there any environments that you are in that do not have a good supply of fresh air? *

Yes No

If so, what are they? *

Do you wear tight-fitted clothes that may restrict your lung expansion? *

Yes No

REST

What is your usual bedtime? *

Do you wake up during the night? *

Yes No

Do you snack before you go to bed? *

Yes No

Do you sleep with a light on? *

Yes No

Do you work the night shift or swing shift? *

Yes No

Do you wake up early in the morning and find it difficult to get back to sleep? *

Yes No

Do you take sleeping pills? *

Yes No

Do you make it a practise to get to bed by a certain time? *

Yes No

Do you rest for your labor at least one day per week? *

Yes No

TRUST

Do you have trust or faith in a higher power? *

Yes No

If you were to describe faith in that higher power, what would it look like? *

What kind of spiritual connection do you participate in on a regular basis? (Prayer, Yoga, Meditation, etc.) *

Do you trust in a higher power with your problems? *

Yes No

Do you suffer from any remorse, guilt, or worry? *

Yes No

If you believe in a higher power, do you believe that you have experienced forgiveness in your life? *

Yes No

Do you struggle with knowing the ultimate purpose for your life? *

Yes No

Would you consider the members of your family to have good relations with each other? *

Yes No

Do you have a spiritually strong immediate family? *

Yes No

Do you consider yourself a person that has peace? *

Yes No

How important is spiritual growth to you? *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

If you are currently in contact with an iHeal Representative, please enter their name below.

Name of iHeal Contact *

First

Last

We thank you for filling the application. By submitting this application, you certify that the answers given are true and complete to the best of your knowledge and authorize an iHeal Representative to contact you in regards to your condition with recommendations.

PLEASE REMEMBER TO CLICK ON THE "SUBMIT ASSESSMENT" BUTTON BELOW

SUBMIT ASSESSMENT