Hope For Health

Combining nature, faith, and love to bring healing to the world...

Free Health Consultation

Please feel free to fill out the information below and it will be sent only to a health counselor, we respect your privacy and never share any of your personal information!

 

If you would like to skip this form you may call us directly at 828-649-0278 or if you are visiting online during our office hours, you may wish to chat with a counselor on the chat line.

 

Your health is of the utmost importance to us, and we will strive to help you quickly, prayerfully, and with our best possible efforts!

 
Health Consultation Request

Fill out the contact information below so we can contact you and serve you as best as we can!
Answer the health questions below to help us serve you better! Be as accurate as you can in your answers.*Sex
Male
Female
*Medical Condition(s) - (Check all that apply)
NONE
Acid Reflux (GERD)  Acne  Allergies  Attention Deficit Disorder (ADD)  Alzheimer's Disease
Anorexia  Arthritis - Osteo  Arthritis - Rheumatoid  Asthma  Back Pain  Bipolar Disorder
Brain Injury  Bronchitis  Bulimia  Bursitis  Cancer – Bladder  Cancer – Brain
Cancer – Cervical/Endometrial/Ovarian  Cancer – Colon/Rectal  Cancer – Kidney  Cancer – Lung  Cancer – Leukemia  Cancer – Non-Hodgkin’s Lymphoma  Cancer – Pancreatic  Cancer – Prostate  Cancer – Skin  Cancer – Other  Celiac Disease  Cholesterol (High)  COPD
Congestive Heart Failure  Crohn's Disease  Depression  Diabetes – Type 1  Diabetes – Type 2
Diarrhea  Disabilities (Mental or Physical)  Diverticulitis  Ear Infections  Ear Problems (Other)
Eczema  Endometriosis  Enlarged Prostate  Epilepsy  Erectile Dysfunction
Eye Problems  Fibromyalgia  Gallbladder Disease  Gallstones  Generalized Anxiety Disorder
Genital Herpes  Glomerulonephritis (Nephritis)  Gout  Headache  Hearing Loss
Heart Disease  Heartburn  Hemorrhoids  Hepatitis  Herniated Discs  Hiatal Hernia
HIV/AIDS  Hives  High Blood Sugar  High Blood Pressure  High Potassium
Hyperthyroidism  Hypothyroidism  Infertility  Insulin Dependent Diabetes Mellitus (IDDM)
Iron Deficiency Anemia  Irritable Bowel Syndrome (IBS)  Itching  Juvenile Rheumatoid Arthritis
Kidney Disease  Kidney Stones  Lupus  Memory Loss  Menopause  Mesothelioma
Migraine  Multiple Sclerosis (MS)  Muscle Cramps  Muscular Dystrophy  Muscle Fatigue
Muscle Pain  Obesity  Osteomyelitis  Osteoporosis  Ovarian Cyst  Pain (General)
Panic Attack  Parkinson's Disease (PD)  Peripheral Artery Disease (PAD)  Peptic Ulcers  Polio
Pneumonia  Post Nasal Drip  Post Traumatic Stress Disorder  Premenstrual Syndrome (PMS)
Psoriasis  Renal Failure  Restless Legs Syndrome (RLS)  Ringworm  Rosacea  Sciatica
Schizophrenia  Sinus Infection  Skin Problems/Rash  Sleep Disorders (Sleep Apnea)  Snoring
Staph Infection (MRSA)  Tuberculosis (TB)  Ulcers  Urinary Tract Infection (UTI)  Varicose Veins
Vertigo  Yeast Infection (Candidiasis)  
Answer the dietary questions below to help us serve you better! Be as accurate as you can in your answers.*How often do you eat fresh, raw, uncooked fruits and vegetables?
Never.
Rarely (when I have to)
Occasionally (I will have a salad or an apple here and there)
Frequently (I usually have something raw a few times a week)
Daily (I try to get at least one or two fresh foods per day)
Constantly (A significant portion of my diet is raw foods)
*Do you eat meat products? (Select all that apply)
Beef
Chicken
Fish
Seafood
Pork
Other
I do not eat meat products.
*Do you eat eggs?
Yes
No
*Do you eat dairy products? (Select all that apply)
Milk
Butter
Ice Cream
Sour Cream
Yogurt
Cheese
Other
I do not eat dairy products.
*Do you consume caffeine? -- Coffee, Tea, Chocolate, Etc. (Select all that apply)
Coffee
Tea
Chocolate
Energy Drinks
Soda
Medications (Excedrin, No Doz, Etc.)
I do not consume caffeine in any form.
*How often do you consume caffeine?
I do not consume caffeine.
I rarely consume caffeine in any form.
Once or twice a week.
Every day.
Multiple times a day.
*What kind of water do you typically drink?
Well water
Tap water (city)
Bottled water (spring, purified, or distilled)
Distilled water (home distilled)
Home purified water (tap or other water that you run through a purifier)
A variety of types. Whatever is on hand.
I do not drink water
*Do you drink alcoholic beverages? (Select all that apply)
I do not drink alcoholic beverages.
Beer
Wine
Spirits (Liquor, etc.)
Other
*Do you drink other (caffeine-free) processed drinks? -- Anything other than water or fresh pressed juice. (Select all that apply)
Caffeine-Free Colas
Storebought Juices
Gatorade or similar drinks
Kool-aid or similar drinks
Diet Drinks (Crystal Light or similar)
Other
I do not drink other (caffeine-free) processed drinks
Answer the lifestyle questions below to help us serve you better! Be as accurate as you can in your answers.*Do you use tobacco?
Cigarettes
Cigars
Snuff
Pipe Tobacco
Chew
I do not use tobacco.