Mercy to All Creation

"To save one life is to save all humanity."

Health Assessment

All fields are required. If a question does not apply, select "Not Applicable".

First Name

Last Name

Phone/WhatsApp *

Email *

Date of birth *

Gender *

Male

Female

Address

Street Address *

City *

State

Country *

Postal Code *

Medical History

Primary Diagnosis *

When did it start? (Year) *

History of sickness progression *

Current Medications *

Weight Trend *

Other Conditions (if any)

Medical Letters / Test Results

Bowel Movement Habits

Daily Frequency (times/day) *

Stool Consistency *

Blood Visible? *

Yes

No

Mucus Visible? *

Yes

No

Daily Activity

Activity Level *

Specific Exercise Type

Dietary Preferences & Habits

Current Primary Diet *

Fast Food Frequency *

Daily Caffeine Intake *

Alcohol Consumption *

Smoking / Vaping *

Lifestyle Factors

Daily Stress (1-10) *

High stress = High Cortisol = Gut Inflammation

Daily Water Intake *

Sleep Quality *

48-Hour Food Recall

Please list what you ate. Type "Skipped" or "N/A" if you did not eat that meal.

YESTERDAY *

LUNCH
DINNER
SNACKS

TODAY *

LUNCH
DINNER
SNACKS

Allergies & Triggers

A "trigger" is a food that doesn't necessarily give you an allergic reaction (like a rash), but makes you feel bad, uncomfortable, or gives you symptoms after you eat it.

Known Allergies *

Suspected Triggers *

Kitchen Equipment

Note: We ask this because the plan includes fresh vegetable and fruit juices, and an Instant Pot saves you a lot of time by cooking meals by itself automatically.

Do you have a Juicer Machine? *

Yes

No

Do you have a Kitchen Weight Scale? (For measuring food portions) *

Yes

No

Do you have an Instant Pot? (Electric Pressure Cooker) *

Yes

No

Who will be preparing your meals? *

I prepare by myself

A family member

Sometimes me, sometimes a family member

Nutrition Budget & Commitment

Health is Wealth

"We strongly recommend prioritizing your budget for high-quality, organic nutrition. By cutting out temporary luxuries (like eating out, subscriptions, or processed snacks), you can significantly increase your budget for the variety of healing foods your body needs. To save your health is to save your future."

Please be accurate, as we will create a tailored plan according to your budget, so this information is very important.

Weekly Food Budget *

Currency: Type your currency name (e.g., USD, EUR, GBP)

Amount: Enter amount (e.g., 200)

Estimated Weekly Food Budget

My Healing Pledge

I promise to follow this natural food plan honestly. I understand that if I "cheat" with processed foods, it will take longer for me to get better. I choose to put my health first, because saving my health is saving my life. *

Yes, I promise!

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