The client intake form is the heart and soul of our treatment program. Your honesty and candor in filling out this form will allow us to give you the best treatment possible. This form is designed to get to the heart of the matter and get you on your way to the most transformative treatment and your most radiant skin. 
 
We take your beauty and your privacy seriously so please know that this form is strictly confidential and will be shared only with your herbalist. 
WHICH AREAS ARE YOU MOST INTERESTED IN FOCUSING ON? *
WHAT FOODS DID YOU EAT MOST OFTEN AS A CHILD? FOR EXAMPLE, CONSIDER SOME OF YOUR MOST COMMON CHILDHOOD MEALS OR INGREDIENTS. PLEASE CHOOSE A FEW OF THE FOLLOWING. *
 
WHAT ARE YOU PREPARED TO CHANGE? PLEASE CHECK THOSE THAT APPLY. *
HOW OFTEN DO YOU DRINK ALCOHOL? *
HOW MUCH WATER DO YOU DRINK EVERY DAY? *
HOW MANY CAFFEINATED DRINKS DO YOU HAVE PER DAY? MATCHA, OTHER TEAS, SODAS AND ENERGY DRINKS COUNT. *
HOW MANY TIMES HAVE YOU BEEN SICK (WITH A COLD, FLU, SINUS INFECTION, ETC.) IN THE LAST 12 MONTHS? *
WHEN YOU DO GET SICK, HOW LONG DOES IT LAST? *
HOW OFTEN DO YOU EXERCISE? (LOTS OF WALKING COUNTS.) * *
IF YOU EXERCISE, WHAT DO YOU DO? *
HOW OFTEN DO YOU EXPERIENCE GAS, BLOATING, OR DIGESTIVE DISCOMFORT? *
HOW WOULD YOU DESCRIBE YOUR AVERAGE LEVEL OF ENERGY? *
HOW OFTEN DO YOU HAVE A BOWEL MOVEMENT? *
WHAT TIME OF DAY ARE YOU HIGHEST ENERGY? *
ON A SCALE OF 1–5, HOW WELL IS YOUR SLEEP? *
WHAT TIME OF DAY ARE YOU LOWEST ENERGY? *
WHAT TIME DO YOU TYPICALLY FALL ASLEEP? *
HOW WOULD YOU DESCRIBE YOUR MOOD ON AVERAGE? *
WHAT TIME DO YOU TYPICALLY WAKE UP? *
DO YOU EXPERIENCE ANXIETY? *
IT’S HELPFUL TO UNDERSTAND YOUR SLEEP IN DETAIL. PLEASE CHECK ALL THAT APPLY. *
 
IF YOU EXPERIENCE ANXIETY, WHAT SYMPTOMS ACCOMPANY IT? *
 
ON A SCALE OF 1-5, WITH 5 BEING EXTREMELY BUSY, WHAT IS YOUR AVERAGE DAILY STRESS LEVEL? *
The next questions are gender specific. Please skip them if your body is not made for menstrual cycles.
ON AVERAGE, HOW MANY DAYS ARE THERE BETWEEN YOUR MENSTRUAL CYCLES? *
HOW SEVERELY ARE YOU AFFECTED BY YOUR PERIOD? PLEASE CHECK ALL THAT APPLY. *
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