Wellness Consultations

Name

Email Address

Why Are You Reaching Out?

What Are Your Top Health Goals?

What Are Your Health Concerns?

Do you use scented candles, FeBreeze, or plug-ins? Do you use scented candles, FeBreeze, or plug-ins? Yes No

List Candle Brands

How Often?

Do you use laundry detergent and dryer balls or sheets? Do you use laundry detergent and dryer balls or sheets? Yes No

List Detergent Brands

How Often?

Do you eat sweets? Do you eat sweets? Yes No

List Brands of Sweets

How Often?

Do you eat dairy? Do you eat dairy? Yes No

List Dairy Brands

How Often?

Do you eat Gluten? Do you eat Gluten? Yes No

List Gluten Brands

How Often?

Do you have any dietary restrictions or allergies?

What kind of exercise activities do you participate in?

Do you have any physical limitations? Do you have any physical limitations? Yes No

If yes, please list them

Do you take any supplements? Do you take any supplements? Yes No

If yes, please list them

Do you have any skin issues? Do you have any skin issues? Yes No

If yes, please list them

Do you have any pertinent family history? Do you have any pertinent family history? Yes No

If yes, please list them

Do you have any pertinent medical history? Do you have any pertinent medical history? Yes No

If yes, please list them

What medications do you take?

Do you drink alcohol? Do you drink alcohol? Yes No

If yes, how oftern?

Do you smoke (anything)? Do you smoke (anything)? Yes No

If yes, what and how often?

Do you experience generalized anxiety? Do you experience generalized anxiety? Yes No

If yes, how often?

Do you have chronic post nasal drainage or nasal stuffiness? Do you have chronic post nasal drainage or nasal stuffiness? Post Nasal Drainage Nasal Stuffiness

Do you experience any regular aches and pains? Do you experience any regular aches and pains? Yes No

If yes, how often?

Any additional information we should know about?