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Confidential Client Health Questionnaire

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Personal Health Analysis:
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.
      2. Please keep in mind that our nutritional products DO NOT cause side effects. Occasionally after starting a nutritional program, you may feel a temporary worsening or even feel “sick.” If this occurs, do NOT cancel your appointment. Immediately call the office. Sometimes these “flare-ups” are actually a “Healing Crisis” which indicates your body is starting to heal by throwing off toxins that have been keeping you sick. By fine-tuning your program, we can help you get through these types of situations much more smoothly, if they even occur. When you are not doing well is when it is often most important to come in so we can fine-tune your program and help you correct the underlying cause of the problem more rapidly.
      3. Please consider all the dynamics in your life that could interfere with or prevent you from doing or completing your health repair program. For this period of time, please put your health first so body can repair the years of damage…and then make it a lifestyle change. Your body will thank you!
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.
Your name will act as your signature