Client Intake Form - Holistic Way Wellness

Client Information

Health History & Wellness Intake Form

Please complete this comprehensive intake form to help me understand your health history, current challenges, and wellness goals. This information is confidential and will help me create your personalized healing plan. Required fields are marked with an asterisk (*).

First Name * Last Name * Email * Phone Number * Date of Birth * Emergency Contact Top 3 Health Concerns/Goals * Do you have chronic health conditions? * If yes, please list conditions Current Medications & Supplements Known Allergies Sleep Hours Per Night * Energy Levels * Exercise Frequency * Describe Your Eating Habits Stress Level (1-10) * Anxiety/Depression/Mood Swings * What brings you joy? Bowel Movement Frequency * Digestive Symptoms (check all that apply) Hormonal Concerns (if applicable) What do you hope to achieve through coaching? * What support/tools do you need? I understand that health coaching is not a replacement for medical care. I consent to participate in coaching with confidentiality. I will always consult my healthcare provider before making changes to medications or treatment plans. *