Thank you for Joining Sarah’s Holistic Health Programs!

We are exciting for your future in a healthy new you!

We will contact you soon!

In the meantime, please fill out the intake forms below and submit them to us.

Intake Form

  • Soda popCoffeeSmokingAlcoholic Bev
  • Fast foodMilkWhite FlourSugar usage
  • Raw fruitMeatRaw VeggiesWhole Grains
  • I understand that I am here to learn about nutrition and better health practices and that I will be offered information about food supplements and herbs as a guide to general good health and this is a personal ministry and spiritual counseling.

    I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purposes or treatment procedures. I am not on this visit or any subsequent visit an agent for federal, state, or local agencies or on a mission of entrapment or investigation.

    The services performed here are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health and do not involve the diagnosing, treatment, or prescribing of remedies for disease.
  • MM slash DD slash YYYY

Toxicity Test

  • MM slash DD slash YYYY
  • Rate each of the following symptoms based on your typical health profile for the last 30 days.

    Point Scale:

    0 - Never or almost never. 1- Occasionally. Effect is not severe2 - Occasionally. Effect is severe 3 - Frequently. Effect is not severe 4 - Frequently. Effect is severe

    Symptoms Questionnaire

  • HeadachesFaintnessDizzinessInsomniaTotal
  • Watery or itchy eyesSwollen, reddened or sticky eyelidsBags or dark circles under eyesBlurred or tunnel visionTotal
  • Itchy earsEaraches, ear infectionsDrainage from earRinging in ears, hearing lossTotal
  • Stuffy noseSinus problemsHay feverSneezing attacksExcessive mucus formationTotal
  • Chronic coughingGagging, frequent need to clear throatSore throat, hoarseness, loss of voiceSwollen or discolored tongue, gums, lipsCanker soresTotal
  • AcneHives, rashes, dry skinHair lossFlushing, hot flashesExcessive sweatingTotal
  • Chest PainIrregular or skipped heartbeatRapid or pounding heartbeatTotal
  • Chest congestionAsthma, bronchitisShortness of breathDifficulty breathingTotal
  • Nausea, VomitingDiarrheaConstipationBloated feelingBelching, passing gasHeartburnIntestinal/stomach painTotal
  • Pain or aches in jointsArthritisStiffness or limitation of movementFeeling of weakness or tirednessPain or aches in musclesTotal
  • Binge eating/drinkingCraving certain foodsExcessive weightWater retentionUnderweightCompulsive eatingTotal
  • Fatigue, sluggishnessApathy, lethargyHyperactivityRestlessnessTotal
  • Poor memoryConfusion, poor comprehensionDifficulty in making decisionsStuttering or stammeringSlurred speechLearning disabilitiesPoor concentrationPoor Physical coordinationTotal
  • Mood swingsAnxiety, fear, nervousnessAnger, irritability, aggressivenessDepressionTotal
  • Mood swingsAnxiety, fear, nervousnessAnger, irritability, aggressivenessDepressionTotal
  • Frequent illnessFrequent or urgent urinationGenital itch or dischargeTotal