Please choose one that best describes you.
Please choose what best describes you state of happiness.
Please check what best describes your level of exercise.
Please be as honest as you can. There is no wrong or bad answer.
Please keep in mind that our assessment and recommendations will be based upon the collection of information from the testing and your information provided in this questionnaire. Please try to be as detailed and thorough as possible.
PERSONAL STATEMENT OF RESPONSIBILITY I understand that I am fully responsible for my own health and wellness. I have the right and ability to accept or refuse any educational or therapeutic sessions offered to me. I release Virginia Grace and Leisha Naja of all liability today and during all future visits. BLOOD ANALYSIS CONSENT AND INDEMNITY With submission of the document, I consent to have capillary blood drawn and my blood analyzed by Virginia Grace and Leisha Naja. I understand that live and dried blood analysis are not medical diagnostic procedures, that they do not replace the advice of a medical practitioner, and that they are utilized as a nutritional assessment and educational tool to assist with dietary and lifestyle recommendations. I hereby indemnify Leisha Naja against any claim regarding my analysis, excluding those arising from malpractice.
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