Initial Visit Questionnaire

I appreciate the opportunity to meet with you to discuss my concerns. You have made it very clear, and I acknowledge that I am to read and sign this agreement and reserve my appointment with a $25.00 non-refundable deposit that will be credited toward my consultation. I am to personally bring or send through mail the completed questionnaire on pages 2-10. Payment in full is due at the time of service.

1) The opinions, advice, and services you offer are primarily educational guidance and not medical advice, and under no circumstances are to be considered by me as such;

2) The opinions, advice, and services that you offer are under no circumstances intended to modify, affect, or to be in lieu of any medical advice or treatment that I may require for any cause whatsoever, now or in the future;

3) You encourage me to consult with my doctor with reference to my particular problem and to keep my doctor fully informed as to the opinions, advice, and services you offer;

4) Your opinions, advice, and services fundamentally relate to an educational program pertaining to the teaching of a more macrobiotic, natural, and traditional diet including nutritional and related principles which many people have found helpful for improving their physical, mental, and spiritual conditions;

5) You have made no promise or representations, expressed or implied, as to any result I might obtain by adhering to your opinions or advice or in accepting your services.

6) I, together with any and all accompanying persons, have completely read the above statements, and acknowledge that I/we fully understand them, and that I/we have received no promises or guarantees whatsoever. I understand that the success of the program is dependent upon many factors including my
cooperation.

I, for good and valuable consideration, release and discharge Virginia M. Harper, You Can Heal You, the officers, employees, representatives, cooks, and agents, from any and all claims and demands of every nature which I now have or may have in the future as a result of accepting and following the advice, opinions, and services offered by Virginia M. Harper and You Can Heal You representatives.

Important: Your name indicated on this line below will stand in as your signature 

Option I A: “Getting Started” Macrobiotic Consultation Package $700 (save $45)

Evaluation, Personalized Program,(includes food protocol, recipes, shopping list),Cooking Class, Study manual, 1-month Coaching.

Option I B: “Getting Started” for couples $1,300 (Save $190)

Evaluation, Personalized Program (includes food protocol, recipes, shopping list),Cooking Class, Study manual, 1-month Coaching each.

Option II: “On Your Way” Macrobiotic Consultation Package $1,065. (save $65)

Same as Option I plus cooking MP and total of 2 months’ coaching

Option III: “Claiming Your Health” Macrobiotic Consultation Package $1,350 ($80)

Same as Option II plus a total of 3 months coaching and $75 PRC needed after program is completed.

Option V: “Healing Lifestyle Training”

A residential hands-on experience. You live the results for 10 days. $6,000

Please check which foods you have eaten regularly in the past and which foods you are eating now.

Please indicate any fluctuations or changes in your weight in the recent past and/or since beginning
a macrobiotic diet:

Please check if you are using or have used any of the following substances:

Alcohol

Tobacco

Coffee

Hallucinogens

Marijuana

Amphetamines

LSD

Cocaine

Other recreational drugs

Birth control pills

Sleeping pills

Aspirin

Diet pills

Vitamins / Supplements

Herbs

Other non-prescription drugs

Hormone pills

Heart medications

Pain killers

Allergy medication

Antibiotics

Anti-Depressives

Other prescription drugs

Please check which vaccinations you have had and at what age you received them:

Have you had any of the following medical treatments? (please indicate the most recent date and results)

Blood Test:

Cat Scan:

MRI:

X-Rays:

Other:

Medical Information (must be filled out)

Please list the names and addresses of your medical doctors:

Personal Health History

In chronological order, please list a brief health history. Include all diagnoses, surgeries (including tonsils, appendix, abortions, etc.) as well as medical treatment such as radiation and chemotherapy. Please include any miscarriages, accidents or broken bones. Note the date, description, for each entry.