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S.P.A. Health Assessment Intake Form
Staying Sharp Spiritually, Physically & Attitudinally.
You may schedule a private or group session for improved health.
Develop your health portfolio with the guidance of Christian Girlfriends.
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Your Name
*
Your answer
Email address
*
Your answer
Phone
*
Your answer
Primary Health Concern
*
Your answer
Prioritize areas you seek improvement: Overall Health
I have this mastered
I'm good/neutral/Do not need to address
I need a little help
Strongly Interested
High Priority, Address immediately
Joint & Muscle health
Sleep
Stress
Fitness
Heart/Circulatory Health
Skin Health/Facials
I have this mastered
I'm good/neutral/Do not need to address
I need a little help
Strongly Interested
High Priority, Address immediately
Joint & Muscle health
Sleep
Stress
Fitness
Heart/Circulatory Health
Skin Health/Facials
Clear selection
I have this mastered
I'm good/neutral/Do not need to address
I need a little help
Strongly Interested
High Priority, Address immediately
Supplements
Nutrition
Blood Glucose
Ketones
I have this mastered
I'm good/neutral/Do not need to address
I need a little help
Strongly Interested
High Priority, Address immediately
Supplements
Nutrition
Blood Glucose
Ketones
Clear selection
Additional Information
Your answer
Home
I have this mastered
I'm good/neutral/Do not need to address
I need a little help
Strongly Interested
High Priority, Address immediately
EMF Home Assessment (Wifi/cell)
Air Purification
Water Purification
Products & Personal Care
I have this mastered
I'm good/neutral/Do not need to address
I need a little help
Strongly Interested
High Priority, Address immediately
EMF Home Assessment (Wifi/cell)
Air Purification
Water Purification
Products & Personal Care
Clear selection
Therapies
No interest
More information please
Strongly Interested
Oxygen Therapies
Infrared Sauna
Hot/Cold Therapy
Brain Training
Brain Tap Health Device
Pulsed Electromagnetic Field Therapy Mat and Coil
Ionic Foot Detox
Grounding Mat
Paraffin Hand Treatment
Body Massagers
Acupressure Mat
Peptides
No interest
More information please
Strongly Interested
Oxygen Therapies
Infrared Sauna
Hot/Cold Therapy
Brain Training
Brain Tap Health Device
Pulsed Electromagnetic Field Therapy Mat and Coil
Ionic Foot Detox
Grounding Mat
Paraffin Hand Treatment
Body Massagers
Acupressure Mat
Peptides
Clear selection
Labwork, Imaging & Assessments/Recommendations/Referrals
No interest
More information please
Strongly interested
Brain SPECT Scan
Brain MRI & EEG
Brain Assessment Cognition
Blood Labs
Cardiac Calcium Score
Hormone Testing
Continuous Pulse Oximeter
No interest
More information please
Strongly interested
Brain SPECT Scan
Brain MRI & EEG
Brain Assessment Cognition
Blood Labs
Cardiac Calcium Score
Hormone Testing
Continuous Pulse Oximeter
Clear selection
No interest
More information please
Strongly interested
Assessment & Treatment of Toxins, Methylation, Mitochondria & Oxidative Stress
GI Map Assessment & Treatment: Bacteria, Parasites and Viral pathogens
Genetic Testing
Vascular Assessment & Treatment
Oral Microbiome
Lymphatic Treatments
No interest
More information please
Strongly interested
Assessment & Treatment of Toxins, Methylation, Mitochondria & Oxidative Stress
GI Map Assessment & Treatment: Bacteria, Parasites and Viral pathogens
Genetic Testing
Vascular Assessment & Treatment
Oral Microbiome
Lymphatic Treatments
Clear selection
Additional Information
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Your answer
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