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Explore Package

$149.00

Name(Required)
Gender(Required)
MM slash DD slash YYYY
Mailing Address(Required)
Marital Status(Required)

Surgery

Medication / Supplements

Water

If you use well water, has the water been tested for safety within the last year?(Required)

Diet/Eating Habits

Which of the following foods do you consume regularly?(Required)
What type of cookware do you use (check all that apply)?(Required)
Do you have a tendency to rush through meals or eat very quickly?(Required)
Do you tend to skip meals?(Required)
Do you take antacids before, during or after your meal?(Required)

Special Diets

Check any of the following special diets you have followed in the past for at least 6 months. Check all that apply.(Required)
Were any of the diets you followed in the past effective?(Required)
Do you have any known or suspected food allergies or food intolerances (i.e. gluten, lactose, etc.)?(Required)

Elimination

On average, how often do you have a bowel movement?(Required)
Color of stool:(Required)
Describe your average stool. Check all that apply.(Required)
Do you have to take a laxative to have a bowel movement?(Required)

Urination

Color of urine:(Required)
Further describe your urination habits. Check all that apply.(Required)

Sleep

What time do you usually go to sleep?(Required)
:
What time do you usually wake up?(Required)
:
Do you sleep in a completely dark room (very little to no light)?(Required)
Is there a television, computer, or electrical appliance within 6 feet of your bed?(Required)

Exercise

How much exercise do you feel you are doing?(Required)
Do you feel your exercise program is benefiting you?(Required)
Do you struggle to lose body fat, despite dieting and exercise?(Required)
Do you feel an increase in energy and well-being a day or two after your workout?(Required)
If you lift weights / do resistance training, generally how long do you take to recover between workouts?(Required)

Personal Care/Products

Beside each product, type the name brand(s) you use most often. Please take time to complete this list. Go to your kitchen and bathrooms and be certain of the brand - no guessing.

Household/Products

Beside each product, type the name brand(s) you use most often. Please take the time to complete this list. Go to your kitchen and bathrooms and be certain of the brand - no guessing.

Smoking / Alcohol & Drug Use

Do you currently smoke (tobacco)?(Required)
If you don't smoke currently, did you smoke in the past?(Required)
Are you or have you been exposed to secondhand smoke?(Required)

Dental Work

Have you had your wisdom teeth extracted?(Required)
Have you had dental surgery (gum surgery, jaw surgery etc.)(Required)
Do you have halitosis (bad breath)?(Required)

Endocrine Function

Rate each condition using the following scale: 5 = severe, 4 = strong, 3 = moderate, 2 = mild, 1 = weak, 0 = not present)

Females Only

Neural Tissues Health

(Rate each condition using the following scale: 5 = severe, 4 = strong, 3 = moderate, 2 = mild, 1 = weak, 0 = not present)

Musculo-Skeleton Health

(Rate each condition using the following scale: 5 = severe, 4 = strong, 3 = moderate, 2 = mild, 1 = weak, 0 = not present)

Carbohydrate Metabolism

(Rate each condition using the following scale: 5 = severe, 4 = strong, 3 = moderate, 2 = mild, 1 = weak, 0 = not present)

Eicosanoid Modulation

(Rate each condition using the following scale: 5 = severe, 4 = strong, 3 = moderate, 2 = mild, 1 = weak, 0 = not present)

Detoxification Capacity

(Rate each condition using the following scale: 5 = severe, 4 = strong, 3 = moderate, 2 = mild, 1 = weak, 0 = not present)

Fat & Protein Metabolism

(Rate each condition using the following scale: 5 = severe, 4 = strong, 3 = moderate, 2 = mild, 1 = weak, 0 = not present)

Existential

Terms of Service

Introduction

It is common practice for naturopaths, nutritionists and other non-licensed practitioners to collect your signature on a form such as this. By doing so you acknowledge and accept that we:

  • are not medically licensed;

  • are not a substitute for advice from a doctor;

  • recommend that you consult your doctor before making any changes to your diet or exercise regime or taking any dietary supplement;

  • are not liable for any losses you may suffer by relying on our advice;

  • do not guaranty results of recommended products;

  • does not guarantee results of recommended products;

  • are not a covered entity or a business associate of a covered entity under HIPAA.

    By your signature below, and/or by instructing us to provide advice and services to you, you indicate your agreement to these terms.

    What we do and do not do

    Your doctor may use the same test results to diagnose and treat disease, but we do not do this. The information we provide is not intended to, cannot, and should not be expected to be a substitute for a personal consultation with your own qualified doctor. We do not accept any liability for any failure to identify any medical condition or disease; this is not the purpose of our services.

    We may provide you with information relating to products that we believe might benefit you, but such information is not to be taken as an endorsement or recommendation. Some such products may not be available without a prescription, but we do not dispense or prescribe any prescription products. The information provided is intended for educational purposes only and should not be taken as professional medical advice or used as a substitute for medical care. We are not responsible for any adverse affects or consequences that may result, either directly or indirectly, from that information.

    Consult your doctor

    We are not qualified medical advisors and make no claims to be so. The information we provide should not be taken to be, and is not a substitute for, personal medical advice and instruction. You should not take any action based solely on our advice. You should consult your doctor:

    You should consult your doctor:

  • for any medical interpretation of your test results;

  • on any matter relating to your health and well-being;

  • before making any changes to your exercise or diet;

  • before taking any nutritional, herbal, homeopathic or hormonal supplementation;

  • before beginning any therapy.

    Exclusion of warranties

    We will provide our services to you with reasonable care and skill. But we make no other warranty, express or implied, with respect to those services. All other warranties are excluded to the maximum extent permitted by law.

    We make no warranty as to the accuracy of the laboratory test results we receive. We make no warranty, expressed or implied, as to the quality or effectiveness of any diagnosis, apparatus, treatment or product. In no event will we be liable for any physical or mental injury, or any negative side effects, that may arise from the use of any such diagnosis, apparatus, treatment or product.

    We believe that the information we provide, including that on our web sites, brochures, flyers and information packets, is accurate, but we cannot guarantee such accuracy. We therefore make no warranty as to the accuracy of that information, and it should not be relied upon as being correct, complete or accurate. It is your responsibility to verify such matters independently from primary sources of information and by taking specific professional advice.

    Exclusion of liability

    If you rely on, buy or use a product or therapy, you do so at your own risk. Each person is different, and the way someone reacts to a product or therapy may be significantly different from another. We cannot predict how you may react to any particular product or therapy.

    To the maximum extent permitted by law, we exclude:

  • any and all liability in contract, tort (including negligence), breach of statutory duty, or otherwise for any direct, indirect, special, incidental, or consequential costs, losses, claims, damages, expenses, or proceedings (including but not limited to loss of profits and wasted management time) incurred or suffered by you arising directly or indirectly out of or in connection with our services, including but not limited to any loss, damage or expense arising from any defect, error, imperfection, fault, mistake or inaccuracy with the information or advice we provide;

  • any and all liability for injury or loss arising out of the use of, or reliance on, the laboratory results and/or the dietary, supplement and lifestyle suggestions we may provide;

  • any and all liability for injury or loss arising from any product or treatment you may choose to take;

  • any and all liability for any failure to identify any medical condition or disease. You understand and agree that this is not the purpose of our services.

    This is a comprehensive limitation of liability that applies to all damages of any kind, including (without limitation) compensatory, direct, indirect or consequential damages, loss of data, income or profit, loss of or damage to property and claims of third parties.

    No recommendation

    All material and information we may provide about products and therapies is provided solely for educational purposes and for use when discussing your health with your doctor. By providing you with such material and information, we do not necessarily endorse, recommend or promote any such product or therapy.

    Refund Policy

    Payment for services must be paid upon receipt of this agreement unless a special promotion offers payments in installment(s). No refunds will be issued by Deeper Health Consulting, Inc., even upon decision of a client not to continue with the full terms/length of the contract.

    Signature

    I have read and understood the above and I agree to it.
  • Name
    MM slash DD slash YYYY

    By typing my name above, I acknowledge that this acts as a legal, electronic signature.

    Description

    Explore = $149 

    Customized lifestyle changes including nutrition and detoxification recommendations 

    Includes:

    Comprehensive intake form/medical history screening to access medical history & lifestyle

    One 60 minute session

    Customized DRESS protocol (Diet, Rest, Exercise, Stress Reduction, Supplementation)

    Paleo Lifestyle customizable guide

    Personalized Physiological Impacts of Stress on Metabolic Function chart

    Simplify & Detoxify

     

    -Discover what toxic chemicals are lurking in your foods and personal care products

    -Caution: organic products may even contain some of these toxins

    -Don't be fooled by terms like "all natural" and "preservative-free"

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