Client detox Health Questionnaire

Name

Address

City

State

ZIP

Best Phone

You will receive exciting healthy news & delicious recipes

Date of Birth

Age

sex

Height

Weight

Health History: List any major illnesses, surgeries, accidents or injuries (with approx. dates):

Current medications, drugs (street or prescribed) or supplements/herbs:

Do you have any known allergies to medications or herbs? (List all)

Personal Health Analysis:

How many times have you been on antibiotics:

Were you breastfed as a child?

Y N

Do smoke cigarettes?

Y N

Are you exposed to second hand smoke or were you in the past?

Y N

How many ounces of water do you drink per day?

How many sodas do you drink per week?

How many cups of coffee do you drink per week?

How many alcoholic beverages do you drink per week?

Would you like your weight to change? (Check one)

No More weight Less weight

What time do you go to bed?

What time do you wake up?

Do you sleep well?

Y N

Do you wake up during the night?

Y N

If so, what time?

What do you feel like when you wake up?

What were your childhood eating habits? (List types of foods)

What % of the food you eat is home cooked?

How many days a week do you eat out?

What are the 3 worst foods you eat?

What are the 3 best foods you eat?

Do you crave sugar?

Y N

Do you crave salt?

Y N

Do you crave carbs

Y N

How many bowel movements do you have per day?

List any known allergies? (Include foods)

Do you a have dairy allergy?

Y N

List areas where you experience pain:

What is your goal for the Detox Purification Program?

How did you hear about the Detox?

When would you like to start the Detox?

Hobbies/Activities:

NUTRITIONAL THERAPY INFORMED CONSENT AND DISCLAIMER for Nourish and Revive, LLC: Heidi Jo Rickard, NTP - Before you choose to use the services of a Nutritional Therapy Practitioner, please read the following information FULLY AND CAREFULLY.

GOAL: Nourish and Revive wants to encourage people to become knowledgeable about and responsible for their own health, and to bring it to a personal optimum level. Nutritional therapy is designed to improve your health but is not designed to treat any specific disease or medical condition. Reaching the goal of optimum health, requires a sincere commitment from you, with possible lifestyle changes, and a positive attitude. As a Nutritional Therapy Practitioner, I am trained to evaluate your nutritional needs and make recommendations of dietary changes and suggest nutritional supplements. As a Healing Master, I am trained to promote relaxation, lower stress levels, help to relieve the symptoms of pain and promote the overall healing process. As an ordained Christian minister, I offer spiritual and energetic guidance. As a Healing Master, Christian Minister and Nutritional Therapy Practitioner, I am not trained to provide medical diagnoses, and no comment or recommendation should be construed as being a medical diagnosis.

HEALTH CONCERNS: If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider. Nourish and Revive, LLC is not a substitute for your family physician or other appropriate healthcare provider nor is licensed to diagnose or treat pathological conditions, illnesses, injuries, or diseases. We offer no treatment or cure of conditions or disease.

Nutritional therapy may be a beneficial adjunct to more traditional care, and it may alter your need for medication, so it is important you always keep your physician informed of changes in your nutritional program. If you are using medications of any kind, you are required to alert Nourish and Revive, LLC to such use, as well as to discuss any potential interactions between medications and nutritional products with your doctor/pharmacist. You agree to discuss all supplementation protocol recommendations with your doctor before usage. If you have any physical or emotional reaction to nutritional therapy, discontinue their use immediately, and contact your doctor and Nourish and Revive, LLC to ascertain if the reaction is adverse or an indication of the natural course of the body's adjustment to the therapy.

I certify that I am not pregnant and if I become pregnant will notify my doctor and Nourish and Revive, LLC immediately to review the recommended protocols. I certify that I am 18 years old or older. COMMUNICATION: Every client is an individual, and it is not possible to determine in advance how your system will react to the supplements. It is sometimes necessary to adjust your program for maximum progress of your nutrition healing. It is your responsibility to do your part by using your nutrition guidelines, exercise your body and mind sufficiently for a positive balance, eat a proper diet, get plenty of rest, and learn about nutrition. You must stay in contact with Nourish and Revive, LLC so we can let you know what is happening and the best course of action. You should request your healthcare providers to contact Nourish and Revive, LLC for answers to any questions they may have regarding nutritional therapy.

DISCLAIMER: Heidi Jo Rickard, NTP is a Nutritional Therapy Practitioner and Healing Master, and is not a licensed physician. A Nutritional Therapy Practitioner ™ is trained by the internationally recognized Nutritional Therapy Association, Inc.® A Healing Master – is trained as a Master in the Healing Arts. Heidi Jo Rickard is an ordained Christian minister through United Christian Faith Ministries. Nourish and Revive does not diagnosis, treat, or cure of any disease, pain, deformity, injury, or physical or mental condition. You should always speak to a healthcare professional before taking any dietary, nutritional, herbal, or homeopathic supplement. Information provided by Nourish and Revive is not a substitute for medical advice nor is it a substitute for consultation with a healthcare provider.

Program Guidelines and Agreement

1. Always consult with your health care professional to see if you are healthy enough for detox. Always consult your doctor about new or modified nutritional and exercise programs you introduce into your life.

starting to heal

doing or completing

By my/our signature(s), I/we confirm that I/we have read and fully understand the above disclaimer and the program agreement, and am in complete agreement thereto and do freely and without duress sign hold harmless and consent to all terms contained herein.

Printed Name

Date

Your name will act as your signature

Victoria D

December 29, 2022.

Heidi has a passion for health and healing. She is such a good listener with a heart for helping. Because she has experienced so much with her own body, she can truly empathize with her clients. She has helped with everything from hair loss to parasites. You name it, she'll find the issue and, a resolution.

Cyndi ONeill-Dady

December 27, 2022.

Without hesitation I highly recommend Heidi Rickard founder of Nourish & Revive to support you on your health & wellness journey. She is extremely knowledgeable, conscientious and professional while always caring, kind and generous. I have appreciated the support and peace of mind Heidi has provided me since 2018. I was diagnosed with Breast Cancer 2017, and along with my Naturopath, and Heidi I have built a trusted team to support my goals to respond naturally, build up my immune system and thrive. I also appreciate her amazing knowledge of supplements that is always in line with my Naturopath's assessment and recommendations.

Judy Gribble

December 11, 2022.

Heidi is an angel! She always has our best interest at heart… Love you Heidi!

Abrianna Sutton

July 27, 2022.

Knows her stuff! Very personable, and genuine. She listens, and cares to improve your health and life

Sara Oldham

February 6, 2022.

I appreciate Heidi’s care and thoroughness. She’s been incredibly supportive and helpful in my health journey.

Heather Morrison

January 15, 2022.

I completed the 21 day Detox with Heidi and I feel amazing! I wasn't hungry at all and it allowed me to break free of the diet soda addiction I had been battling for a lifetime. Heidi makes the process so easy. It's all very well planned out and the recipes are easy, delicious and made me appreciation whole foods again. She checked in with me during the process as well as after to make sure I had a smooth transition off of the detox on Day 22. This is going to be an annual part of my wellness journey! Thanks, Heidi!!!

Jessica Szymas

December 21, 2021.

Heidi has been an incredible support for me over the past couple of years. I was gifted an hour of energy work by a friend & now I book regular appointments that facilitate me being more grounded, mentally clear and overall energetically healthy. I also did the detox program this Fall & it's the healthiest I've felt in years. I'd highly recommend Heidi and her services! She's so in tune & goes beyond to offer good care!

Amber Maurina

September 2, 2021.

Heidi is so lovely. She totally trusted me and my own body and helped me heal completely! I prefer natural methods to western medicine and Heidi is a very kind, egoless, and knowledgeable practitioner. When she was recommended to me - the person said that Heidi was who they go to when nobody else can figure out what’s going on. And they were totally right!

Shawn O'Neill

April 11, 2021.

I went to Heidi for healing energy work. I had a number of questions and Heidi was kind and patient and I came away with a much greater understanding of healing practices. she is an intuitive practitioner and I will look to Heidi for advice in all manner of healing. Mind, body and soul. I highly recommend Heidi!

Christa Johnson

March 10, 2021.

My husband and I did the 21 day detox/cleanse. So much better than anything else we’ve tried! Our goals were to lose weight and reset our diet, which this did. We now have cleared direction about what our bodies need for nourishment. Heidi was great to work with- so caring and helpful. We highly recommend Nourish and Revive!