Luxewellness Intake Form

Please complete the following patient information in order to participate in our coaching programs, events or retreat activities

First name

Last name

Phone

Date Of Birth

Day

Month

Year

Address

Emergency Contact Name

Emergency Contact Phone

What is your main health and wellbeing concern or personal focus? (Please list any current or previous health issues that may be important to know)

What would you like to achieve from our session/event together?

What have you done in the past to work on your health & wellbeing concerns, if any (include both alternative & traditional modalities)?

What has proven effective?

What is your current diet like? Please be specific: list the times you eat breakfast, lunch, dinner, and snacks and what you typically eat. Please list any caffeinated drinks, teas, energy drinks, juices or soft drinks.

Do you drink alcoholic beverages ? If so how many glasses/drinks per day or per week do you drink? Please list types of alcohol, mixers, soft drinks or juices ?

On a scale of 1-10 how would you rate your stress levels on a day to day basis? 1 being low stress, 10 being high stress.

On a scale of 1-10 how would you rate your emotional state / levels on a day to day basis? 1 being sad, depressed, lonely, 10 being happy and excited about life.

What obstacles or challenges arise in relation to diet/lifestyle/stressors/emotions?

Are you using any stress or emotional management techniques such as breathwork, meditation, exercise or body movement classes?

Are you taking any prescription medications or supplements? Please list what you take and what it’s for.

How would you like your health and wellbeing to be 30 days from now? How about 90 days from now? How would you feel if you got this result?

What are 5 things you LOVE about your life?

Your Signature

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