Consultation

SONLIGHT MINISTRY CONSULTATION FORM

First Name

Last Name

Age

Height

Weight

Address

Phone

Marital Status

Is the patient and all family members in agreement with natural treatment?

Diagnosis from Doctor (if any)

Are you currently being treated for any health conditions?

If yes, what?

Have you taken the Jab?

What condition(s) you would like us to address?

Have you had any chemotherapy or radiation treatments?

If yes, when and how long were the treatments?

Any Pain?

How many bowel movements in a day?

How many times do you urinate during the night?

Appetite – fair, good or poor?

Do you exercise daily?

Sleep – good fair or poor?

Are you taking any prescription medications?

If yes, what are they?

Are you taking any herbs or vitamins?

If yes, what kind?

Have you had any surgery(ies)?

Females - under or over 50 yrs old, are you still having a monthly menstrual cycle?

If yes, how many days are they bleeding, is the flow heavy?

Females – Do you have any children?

Blood Pressure

Blood Sugar

Do you smoke or use tobacco products?

Do you consume any alcohol?

Diet(typical meals)

Do you eat any flesh meat (including fish)?

Do you eat any meat analogs (fake meats)?

Do you eat any dairy products?

Do you eat any sugar(refined or natural)?

How many glasses of water do you drink in a day?

Do you drink any sodas or juice, coffee, tea?

Do you use any condiments?

Do you eat any refined white products(i.e., flour, rice, bread, etc

How many raw vegetable salads do you eat in a week?

Do you eat fruit daily?

Do you snack between meals?

Current Occupation

READ THEM THIS DISCLAIMER This disclaimer is to serve as notice that the health information we (Centurion Bible School Of Health) receives during this assessment/consultation is for general education purposes and is not intended to be used as medical advice, care, diagnosis, prescription or treatment. Therefore, this releases Centurion Bible School of Health from any and all liability. This disclaimer also serves as notice to the receiver that he or she is free to seek medical attention, advice, treatment, diagnosis, etc. from licensed medical personnel. Feel free to add any additional comments below: