| heal_scotland_questionairre.odt |
Heal Scotland Community and Education questionairre
Name
Address
Date of birth
Star sign
No of siblings and place in family
Health and wellbeing issues
Diagnosis
Prognosis
Length of time with this problem
Meditation and treatment now
Medication and treatment over last 10 years
And 20+ years
SYMPTOMS( both physical and emotional):
ENERGY: (is there a best time of day or worst time of day?Does it fluctuate during the day?)
CONCENTRATION/SHORT TERM MEMORY:
SLEEP: (is going to sleep easy, is sleep disturbed, do you get up during the night if so, around what time?)
Physical symptoms (details)
HEADACHES: (if you do suffer from headaches, where do they start, where are they located(frontal or temporal) how long do they last, how often do they occur. any food triggers?any nausea/vomiting accompanying the pain?)
HAIR AND SCALP PROBLEMS:
EYES: (include vision problems such as shortsightedness, itchiness, pain, gritty feeling, dryness etc)
EARS:
THROAT:
LUNGS:
SKIN IN GENERAL:
DIGESTION:( any bloating, burning, reflux gas or any discomfort)
Stomach:
Bowels:( how often do you empty your bowel/what are your stools like/any difficulty in passing them/ what consistency are they: loose, sticky, rabbit droppings etc.../any bad smell?)
BLOOD SUGAR ISSUES: any dizziness, shakyness, cravings for sweets, sudden drop in energy levels, needing to eat small meals and often, relying on carbohydrates for sudden drop in energy levels etc....
BLOOD PRESSURE:
Emotional issues (anything you are aware of which is troubling you at present)
How often do you feel stressed?
PAST HISTORY
In this section, try to let me know about your health from birth and if there were some particular difficulties in your life while growing up. Any health issues too would be quite important. The questions here are for guidance and to help you keep to a time line.
BIRTH: easy/late/ premature/caesarian section/blue baby/etc...
Vaccinations
POSITION IN FAMILY: + details of health of siblings
PREGNANCY/BIRTH: did mother have easy pregnancy. give details, if known
BREASTFED: if so,how long for
NFANCY: give details of any health/emotional issues or traumas/ significant events or illness
HEALTH IN CHILDHOOD
HEALTH IN TEENS
HEALTH IN TWENTIES:
HEALTH IN THIRTIES:
HEALTH IN FORTIES:
HEALTH IN FIFTIES
And beyond if applicable
Health of parents and both sets of grandparents, please be specific. Age of death and cause is applcable.
Do you dream? Often, never, vivid, restless please be specific...
HOLISTIC HEALING MODALITIES
Which of the following have you tried in your healing journey
Do you have any addictions
Please just answer what you feel, this just helps give us an insight to your needs.
What would be the greatest advantages to being free of this condition?
What would you have to give up or change?
What are you not willing to give up or change?
DIET AND EXERCISE IN DEPTH
Water: How much water do you drink each day?
Salads: How many times each day do you eat a salad as a main course?
Vegetables: How many servings (picture a serving as the size of your fist) of vegetables do you eat each day?
Fruit: How many servings of fruit (picture a serving as the size of your fist) to you eat each day? What fruit do you eat?
Cardio (duration): How many minutes of cardio to you get each day?
Cardio (type): What type of cardio do you do each day of the week? (running, cycling, swimming…/intervals, steady state…/hard, moderate, easy)
Cardio (frequency): How many days a week do you do your cardio? (break this down to your daily routine)
Cheating: What are your cheat foods, i.e., foods that you have trouble giving up that you believe are preventing you from making progress toward your goals?
Cheating: How often do you eat or drink them? How do you believe you can eliminate these foods?
Derailed: When you are unable to stick with healthy food choices, what is the reason you get derailed? Do you take full responsibility for this or do you blame others/situations?
Working out: How many days a week do you work out with weights/body weight as resistance? Describe:
Your Challenges: What do you believe would be your biggest challenges with following a nutrition program?
Results: Why do you believe you don’t have the results you want right now?
Journaling: Are you willing to write down everything you eat for a minimum of 12 weeks on this program? I mean EVERYTHING! If not, why?
Positive Imagery: Do you use positive imagery, i.e., do you see yourself where you want to be/feel/look like?
Do you drink alcohol? □ Yes □ No If so, what do you drink?
How Much & How often?
How often do you drink coffee?
How often do you drink soft drinks?
Do you drink diet soda?
Do you overeat? □ Yes □ No If so, which foods and how often?
Do you have any food allergies, environmental allergies, restrictions, or sensitivities? If so, please list them here:
Do you get noticeably irritable, lightheaded, or weak if you haven’t eaten in a few hours?
Please list any food aversions and/or foods you dislike:
How often do you eat home/cook food?
Do you crave any of the following frequently? □ Sweets/Desserts □ Meat □ Peanuts □ Chocolate □ Fish □ Alcoholic Drink □ Diet Sodas □ Milk/Cheese □ Bread/Pasta □ Salty Foods □ Fried Foods □ Sour Foods □ Spicy Foods □ Bland Foods □ Candy □ Fats □ Other
Which oils do you currently consume? □ Butter □ Sesame Oil □ Soybean Oil □ Margarine □ Peanut Oil □ Canola Oil □ Olive Oil □ Corn Oil □ Sun/Safflower Oil □ Coconut Oil □ Crisco □ Mayonnaise □ Flaxseed Oil □ Vegetable Oil □ Other
Do you know what your blood pressure is?
Do you know your cholesterol level?
PAST ISSUES TO BE RELEASED AND RESOLVED
Please list all the issues you would like to work on
Divorce or Breaking Up
Workaholic Stress or Anxiety
Procrastination Fears or Phobias
Chronic Pain Weight Issues
Self Esteem Depression
Grief Marriage Problems
Business Performance
Traumatic Memories
Anger, Frustration, Resentment
Sexual Problems
Prosperity Lack of Joy
Lack of Purpose
Did you have a strong religious upbringing?
Separate school?
Any surgeries as a child?
Please include any memories that you think are holding you back. When did it start and what was going on at the time?
If you were to live your life over, what person or event would you prefer to skip?
What makes you angry and why?
When was the last time you cried and why?
What is your biggest regret or sadness?
Would anyone be upset if you were completely healed?
What are three positive goals you would like to achieve?
If the Community was amazingly successful, what would change for you?
What do you want from the Community?
Are you willing to commit to the good days and more challenging days if they come up?
Have you done any other healing or relaxing Retreats? Please be specific
Are you tolerant and compassionate to others?
What do you think will be your biggest challenge/s?
Are you willing to let go of the past?
Do you believe right now that you can heal?
Will you be 100% honest with your guides and therapists?
What do you think you can bring to the Community?
Name
Address
Date of birth
Star sign
No of siblings and place in family
Health and wellbeing issues
Diagnosis
Prognosis
Length of time with this problem
Meditation and treatment now
Medication and treatment over last 10 years
And 20+ years
SYMPTOMS( both physical and emotional):
ENERGY: (is there a best time of day or worst time of day?Does it fluctuate during the day?)
CONCENTRATION/SHORT TERM MEMORY:
SLEEP: (is going to sleep easy, is sleep disturbed, do you get up during the night if so, around what time?)
Physical symptoms (details)
HEADACHES: (if you do suffer from headaches, where do they start, where are they located(frontal or temporal) how long do they last, how often do they occur. any food triggers?any nausea/vomiting accompanying the pain?)
HAIR AND SCALP PROBLEMS:
EYES: (include vision problems such as shortsightedness, itchiness, pain, gritty feeling, dryness etc)
EARS:
THROAT:
LUNGS:
SKIN IN GENERAL:
DIGESTION:( any bloating, burning, reflux gas or any discomfort)
Stomach:
Bowels:( how often do you empty your bowel/what are your stools like/any difficulty in passing them/ what consistency are they: loose, sticky, rabbit droppings etc.../any bad smell?)
BLOOD SUGAR ISSUES: any dizziness, shakyness, cravings for sweets, sudden drop in energy levels, needing to eat small meals and often, relying on carbohydrates for sudden drop in energy levels etc....
BLOOD PRESSURE:
Emotional issues (anything you are aware of which is troubling you at present)
How often do you feel stressed?
PAST HISTORY
In this section, try to let me know about your health from birth and if there were some particular difficulties in your life while growing up. Any health issues too would be quite important. The questions here are for guidance and to help you keep to a time line.
BIRTH: easy/late/ premature/caesarian section/blue baby/etc...
Vaccinations
POSITION IN FAMILY: + details of health of siblings
PREGNANCY/BIRTH: did mother have easy pregnancy. give details, if known
BREASTFED: if so,how long for
NFANCY: give details of any health/emotional issues or traumas/ significant events or illness
HEALTH IN CHILDHOOD
HEALTH IN TEENS
HEALTH IN TWENTIES:
HEALTH IN THIRTIES:
HEALTH IN FORTIES:
HEALTH IN FIFTIES
And beyond if applicable
Health of parents and both sets of grandparents, please be specific. Age of death and cause is applcable.
Do you dream? Often, never, vivid, restless please be specific...
HOLISTIC HEALING MODALITIES
Which of the following have you tried in your healing journey
- Meditation
- Yoga or Qigong
- Juicing
- Fasting
- Herbs and supplements
- Plant medicines
- Enemas
- Essential oils
- Visualisation/Hypnosis
- EFT/Sedona Method or any other emotional release technique
- Please add anything else not on the list
Do you have any addictions
- Food
- Drink
- Drugs legal or othewise
- Relationships
- Repeating patterns
- Emotional reactions
Please just answer what you feel, this just helps give us an insight to your needs.
What would be the greatest advantages to being free of this condition?
What would you have to give up or change?
What are you not willing to give up or change?
DIET AND EXERCISE IN DEPTH
Water: How much water do you drink each day?
Salads: How many times each day do you eat a salad as a main course?
Vegetables: How many servings (picture a serving as the size of your fist) of vegetables do you eat each day?
Fruit: How many servings of fruit (picture a serving as the size of your fist) to you eat each day? What fruit do you eat?
Cardio (duration): How many minutes of cardio to you get each day?
Cardio (type): What type of cardio do you do each day of the week? (running, cycling, swimming…/intervals, steady state…/hard, moderate, easy)
Cardio (frequency): How many days a week do you do your cardio? (break this down to your daily routine)
Cheating: What are your cheat foods, i.e., foods that you have trouble giving up that you believe are preventing you from making progress toward your goals?
Cheating: How often do you eat or drink them? How do you believe you can eliminate these foods?
Derailed: When you are unable to stick with healthy food choices, what is the reason you get derailed? Do you take full responsibility for this or do you blame others/situations?
Working out: How many days a week do you work out with weights/body weight as resistance? Describe:
Your Challenges: What do you believe would be your biggest challenges with following a nutrition program?
Results: Why do you believe you don’t have the results you want right now?
Journaling: Are you willing to write down everything you eat for a minimum of 12 weeks on this program? I mean EVERYTHING! If not, why?
Positive Imagery: Do you use positive imagery, i.e., do you see yourself where you want to be/feel/look like?
Do you drink alcohol? □ Yes □ No If so, what do you drink?
How Much & How often?
How often do you drink coffee?
How often do you drink soft drinks?
Do you drink diet soda?
Do you overeat? □ Yes □ No If so, which foods and how often?
Do you have any food allergies, environmental allergies, restrictions, or sensitivities? If so, please list them here:
Do you get noticeably irritable, lightheaded, or weak if you haven’t eaten in a few hours?
Please list any food aversions and/or foods you dislike:
How often do you eat home/cook food?
Do you crave any of the following frequently? □ Sweets/Desserts □ Meat □ Peanuts □ Chocolate □ Fish □ Alcoholic Drink □ Diet Sodas □ Milk/Cheese □ Bread/Pasta □ Salty Foods □ Fried Foods □ Sour Foods □ Spicy Foods □ Bland Foods □ Candy □ Fats □ Other
Which oils do you currently consume? □ Butter □ Sesame Oil □ Soybean Oil □ Margarine □ Peanut Oil □ Canola Oil □ Olive Oil □ Corn Oil □ Sun/Safflower Oil □ Coconut Oil □ Crisco □ Mayonnaise □ Flaxseed Oil □ Vegetable Oil □ Other
Do you know what your blood pressure is?
Do you know your cholesterol level?
PAST ISSUES TO BE RELEASED AND RESOLVED
Please list all the issues you would like to work on
Divorce or Breaking Up
Workaholic Stress or Anxiety
Procrastination Fears or Phobias
Chronic Pain Weight Issues
Self Esteem Depression
Grief Marriage Problems
Business Performance
Traumatic Memories
Anger, Frustration, Resentment
Sexual Problems
Prosperity Lack of Joy
Lack of Purpose
Did you have a strong religious upbringing?
Separate school?
Any surgeries as a child?
Please include any memories that you think are holding you back. When did it start and what was going on at the time?
If you were to live your life over, what person or event would you prefer to skip?
What makes you angry and why?
When was the last time you cried and why?
What is your biggest regret or sadness?
Would anyone be upset if you were completely healed?
What are three positive goals you would like to achieve?
If the Community was amazingly successful, what would change for you?
What do you want from the Community?
Are you willing to commit to the good days and more challenging days if they come up?
Have you done any other healing or relaxing Retreats? Please be specific
Are you tolerant and compassionate to others?
What do you think will be your biggest challenge/s?
Are you willing to let go of the past?
Do you believe right now that you can heal?
Will you be 100% honest with your guides and therapists?
What do you think you can bring to the Community?
