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Take the first step towards optimal cellular health. Complete our comprehensive health intake form and schedule your personalized wellness consultation.

Free Consultation

No cost, no obligation initial consultation

60-90 Minutes

Comprehensive health assessment and personalized recommendations

Expert Guidance

Meet with our certified wellness professionals

Personal Information

Let us know how to reach you and when you'd prefer to meet.

Full Name *

Age

Email Address *

Phone Number *

Preferred Date

Preferred Time

Morning (9-12 PM)

Afternoon (12-5 PM)

Evening (5-8 PM)

Flexible

Client Health Intake Form

Please complete this comprehensive assessment to help us provide personalized recommendations.

Section 1: Water Intake

How much water do you typically drink in a day?

Less than 1 liter

1-2 liters

More than 2 liters

Do you regularly consume caffeinated or sugary drinks?

Yes

No

How often do you feel thirsty during the day?

Rarely

Occasionally

Often

Section 2: Stress Management

How would you rate your current stress level?

Low

Moderate

High

What activities or strategies do you use to manage stress?

How often do you feel overwhelmed or unable to cope?

Rarely

Occasionally

Frequently

Section 3: Sleep Habits

How many hours of sleep do you get on average per night?

Less than 5 hours

5-7 hours

7-9 hours

More than 9 hours

Do you have trouble falling or staying asleep?

Yes

No

Do you follow a consistent sleep schedule?

Yes

No

Section 4: Exercise Habits

How often do you exercise?

Rarely

1-2 times per week

3-5 times per week

Daily

What type(s) of exercise do you typically engage in? (Check all that apply)

Aerobic (e.g., running, swimming)

Strength training

Flexibility (e.g., yoga, stretching)

Other:

Do you feel satisfied with your current exercise routine?

Yes

No

Section 5: Eating Habits

How would you describe your current diet?

Balanced (includes fruits, vegetables, proteins, whole grains)

High in processed or sugary foods

Inconsistent or irregular meals

Do you regularly skip meals?

Yes

No

How many servings of fruits and vegetables do you consume daily?

None

1-2 servings

3+ servings

Section 6: Social Habits

How often do you engage in social activities or connect with others?

Daily

A few times a week

Rarely

Do you feel supported by your social circle (family, friends, colleagues)?

Yes

No

What activities do you enjoy doing with others?

Goals and Priorities

Which areas of your health are you most interested in improving? (Check all that apply)

Water intake

Stress management

Sleep habits

Exercise habits

Eating habits

Social habits

Are there any specific goals or concerns you would like to talk about?

Next Steps

After reviewing the form, we will work together to create a personalized plan to help you achieve your health goals.

This consultation is completely free with no obligation. We'll review your comprehensive health intake and contact you within 24 hours.

After reviewing your form, we will work together to create a personalized plan to help you achieve your health goals.

Empowering individuals to become the owner of their health through holistic wellness and cellular optimization.

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