Client Intake Form – Rituals & Roots

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Client Intake Form
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Home
About
- What Is Ayurveda?
Services
Contact
Client Intake Form
The Boutique Spa

Client Intake Form

Before your consultation please fill out the health wellness intake form. This will help me better prepare for your consultation.

You will also be asked to keep a food diary of everything you’ve eaten and drank over a 3-day period. As well as times you’ve eaten.

You are also encouraged to take the free Ayurveda body map quiz from Joyful Belly.

Name *

First

Last

Phone #

Email *

How did you hear about Rituals & Roots?

Zen Body & Skin client
Google Search
Social Media
Referral
Other

What services are you interested in?

Nutritional coaching
Lifestyle coaching
Self-care rituals
Spices & herbal remedies
Mindset medicine
Frequency healing (sound healing, tuning forks)
Spa services
Group wellness programs

What are you main goals ?

Make healthier food choices
Make healthier lifestyle choices
Improve gut health
Lose weight
Learn self-care rituals
Help change mindset about health & wellness
Work on self-love
Other (please explain below)

Your other goals

what is your age group?

20's
30's
40's
50's
60's
70+

Do you have any allergies or senstitivies?

Yes
No

Please list any allergies or sensitivities you have

Are you under a medical Dr's care for any reason?

Yes
No

If you are under a Dr's care please explain below

Please list any medications (over the counter or prescribed) you are taking along with any supplements.

Please list any health concerns you have and when they started.

What do you feel is the biggest obstacle to your ideal health?

Too busy to cook or exercise
Lack of motivation
Feel tired all the time
I'm not sure how to eat healthy
I hate exercising
Health issues
Lack of support from friends and family
Unresolved emotions/trauma
Unhealthy habits that are difficult to break
Other (please explain below)

Other issues holding you back

How would you describe your health

I'm in great health, I'm just here to learn more
No major health issues, but I'd like to do better and work on prevention of disease
I'm really struggling with my health right now

Do you smoke?

Regularly
On Occasion
Never

Do you drink alcohol?

I don't drink
I indulge a little too much
In moderation

How well do you sleep at night?

I get a full 7-8 hours and wake up refreshed
I wake up frequently during the night
I suffer from insomnia

How is your stress level?

I'm a high stress person
Stress free!
Moderate stress

When you experience stress, what are your coping mechanisms?

How is your diet? (click all that apply)

I eat healthy most of the time
Most of my meals I cook at home
I do my best but sometimes indulge too much
I really struggle with making healthy choices
I eat out a lot
I eat a lot of leftovers
I frequently microwave my food

How is your relationship with food?

Food is nourishing and healing and I enjoy eating
Eating often makes me feel guilty
I often overeat and feel heavy and bloated afterwards
I have now or in the past suffered from eating disorders

What is your water intake like? (click all that apply)

I do not like water
I always feel thirsty
I gulp large glasses of water at a time
I like my water ice cold
I drink my water warm
I drink a lot of soda/coffee
I sip on water all day long
I drink a large amount of water at mealtimes

What is your elimination like?

1-2 times a day
Less than once a day
Shape and consistency of a banana
I often have constipation
I often have diarrhea
I need coffee to eliminate
I often see undigested food
I often see mucus in my stool

How often do you exercise?

I exercise frequently (at least 3-5 times a week)
I exercise too much and sometimes push myself too hard
I don't exercise
Sometimes I exercise but I don't have a good routine

Please list things you do for selfcare (hobbies, prayer, meditation, time with family or pets, exercise, facials, massages, etc)

I understand all nutrition and lifestyle advice is from an Ayurveda perspective. I understand this is not medical advice, is not meant to treat or cure any disease, and should not take precedent over a Medical Doctors instructions. I understand if I am experiencing a severe medical condition or unexplained pain I should seek out a medical doctor.

I understand

I understand before starting any new diet or exercise plan it is recommended I consult with a medical professional first.

I understand

Home
About
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Contact
Client Intake Form
The Boutique Spa

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