consultation Intake form

Full Name

Date of Birth

Email Address

Phone Number

How did you hear about us?

Have you been diagnosed with any medical conditions?

Yes

No

If yes, please describe your medical conditions

Are you currently taking any medications or prescriptions?

Yes

No

If yes, please list your medications or prescriptions

Have you had any surgeries or hospitalizations in the past 5 years?

Yes

No

If yes, please describe your surgeries or hospitalizations

Do you have any known allergies (food, environmental, or otherwise)?

Yes

No

If yes, please describe your allergies

What are your primary health concerns or symptoms that brought you here?

How long have you been experiencing these symptoms?

Rate your current energy levels (1 = very low, 10 = excellent)

Rate your current stress levels (1 = very low, 10 = very high)

Describe your typical daily diet

How many glasses of water do you drink per day?

How many hours of sleep do you get per night?

Do you exercise regularly?

Yes

No

If yes, describe frequency and type of exercise

Do you smoke or use tobacco products?

Yes

No

Do you consume alcohol?

Yes

No

If yes, how often do you consume alcohol?

Are you currently taking any vitamins, supplements, or herbal remedies?

Yes

No

If yes, please list all vitamins, supplements, or herbal remedies

What are your top wellness goals?

What does feeling your best look like to you?

Is there anything else you would like Mrs. Kae to know before your consultation?

CONSENT: I understand this consultation is educational in nature and is not intended to diagnose, treat, cure, or prevent any disease. Type "I agree" to confirm.

CONSENT: I consent to my information being used to personalize my wellness recommendations. Type "I consent" to confirm.