Detox & Renewal Wellness Intake
Please complete this wellness intake before your consultation. It will help us better understand your goals, lifestyle, environmental exposures, and the areas where your body may benefit from gentle detox and restorative support.
What this intake covers
- Your current wellness goals
- Lifestyle and daily habits
- Environmental and household exposures
- Digestive and detox readiness
- Supplement and wellness history
- Additional health information to support a thoughtful consultation
This intake is designed to support a more personalized wellness experience and help guide a gentle, restorative approach.
Personal Information
Full Name
Email Address
Phone Number
Date of Birth
City / State / Country
Your Wellness Goals
What are your main wellness goals right now?
What would you most like support with?
- Energy
- Digestion
- Bloating
- Skin clarity
- Mental clarity
- Sleep
- Stress support
- Immune support
- Hormonal balance
- Gentle detox support
- Environmental exposure support
- General wellness reset
How long have these concerns been present?
- Less than 1 month
- 1–3 months
- 3–6 months
- 6–12 months
- More than 1 year
Areas You Would Like to Explore
- Heavy metals
- Pesticides / environmental chemicals
- Parasite support
- Mold / home environment
- Water quality
- Digestive balance
- Stress and lifestyle overload
- General detox and drainage support
Lifestyle & Daily Habits
How would you describe your current diet?
- Mostly whole foods
- A balance of whole and processed foods
- Mostly convenience foods
- Specialized diet
How much water do you drink daily?
- Less than 4 glasses
- 4–6 glasses
- 6–8 glasses
- 8+ glasses
Do you exercise regularly?
- Yes, consistently
- A few times per week
- Occasionally
- Rarely
How would you rate your stress level?
Scale 1–10
How is your sleep?
- Restful
- Fair
- Interrupted
- Poor
Environmental Exposure
Are you regularly exposed to any of the following?
- Pesticides / herbicides
- Mold or damp spaces
- Plastics / food storage containers
- Household cleaners / fragrances
- Heavy metals
- Non-stick cookware
- Conventional beauty or personal care products
- Poor air quality
- Unsure
What is your main water source?
- Filtered water
- Bottled water
- City water
- Well water
- Unsure
Has your home had leaks, water damage, or mold concerns?
- Yes
- No
- Unsure
Digestive & Detox Readiness
Do you experience any of the following?
- Bloating
- Gas
- Constipation
- Loose stools
- Diarrhea
- Nausea
- Food sensitivities
- Skin flare-ups
- Fatigue after meals
- No significant digestive symptoms
How often do you have a bowel movement?
- More than once daily
- Once daily
- Every other day
- A few times per week
- Less than a few times per week
Do you sweat regularly through exercise or sauna?
- Yes
- Occasionally
- Rarely
Wellness History
Are you currently taking supplements, herbs, probiotics, or detox products?
Please list them here.
Have you done any detox or cleanse program before?
Please share anything that worked well or did not work well for you.
Additional Support Areas
Have you experienced any of the following recently?
- Brain fog
- Low energy
- Skin irritation
- Headaches
- Sleep disruption
- Mood swings
- Frequent illness
- Chemical sensitivity
- Sugar cravings
- None of the above
Have you traveled internationally in the past 2 years?
Do you have regular contact with animals, farms, untreated water, or undercooked foods?
Important Health Information
Are you currently under a doctor’s care for a significant health condition?
Are you pregnant, breastfeeding, or trying to conceive?
Do you have any major health concerns you would like me to know about before we begin?
Your Vision
What does feeling your best look like for you?
How ready are you to make supportive lifestyle changes?
Scale 1–10
Consent
- I understand this form is for wellness support and education.
- I understand this does not replace medical care or diagnosis.
- I understand I should seek medical care for urgent or serious symptoms.
- I confirm that the information I provided is accurate to the best of my knowledge.
Complete Your Intake
Please complete the form below to begin your wellness review.
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