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Wild Roots Wellness Intake Form 
Email *
I understand that I am here to learn about nutrition and better health practices, that I will be offered information about food supplements and herbs as a guide to general good health, and this is a personal ministry and spiritual counseling. 
I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purpose or treatment procedures. 
I am not on this visit, or any subsequent visit, an agent for federal, state or local agencies or on a mission of entrapment or investigation. 
The services performed here are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health, and do not involve the diagnosing, treatment or prescribing of remedies for disease. 
I also understand that healing takes time. I may not see results within days but I am committed to my healing journey. 
No statement or product has been evaluated by the FDA and is not a substitute for your medical nor does it diagnose or treat any disease.
Please consult your medical doctor or pharmacy if you are concerned about any contraindications. If you are pregnant or breastfeeding, please let me know! 
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Name   *
Age  *
Email - please note you are giving me permission to email you - I will not spam you!  *
Phone number - please note you are giving me permission to text/call  *
Do you have high blood pressure?  *
How would you describe your "diet?"  *
Let me know what else is going. What you have tried that worked or didn't work!  *
Do you have any diagnoses? If so, who diagnosed you and who is your MD?
Ex: Hypothyroidism. 


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Do you have any food, medicine, or environmental allergies/intolerances?  *
What personal care products and household products (including laundry soap, fabric softener, etc..) do you use?  *
Are you in pain? 
Please list any medications you are taking.  *
What are your top three ailments/struggles?  *
What are your top three health goals?  *
What medical doctors are you seeing? Are you on any prescriptions? 
Are you taking any supplements or over the counter meds? 
Have you ever seen any type of natural-minded health professionals? For example, Massage Therapists, Chiros, Acupuncturist, etc...
Have you ever used any plant meds? If so, what were the results? Are you still using them?  *
Describe your sleep pattern to me 
How many hours of sleep do you average a night? 
Do you have trouble falling asleep? 
Do you have trouble staying asleep? 
Do you wake up feeling rested? 
Do you have a sleep routine? 
Do you use any sleep aids? Prescription or otherwise
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How much direct sunshine do you get a day? 
What is your diet like? What is the healthiest thing you have eaten this week? What is the unhealthiest thing you have eaten this week? 

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Do you enjoy any type of exercise or movement? Yoga, walking, dancing, Hiit workouts, gardening, etc... *
How much water do you drink a day? What type of water? 
How much caffeine do you consume a day? 
Bowel Movements: 
How often do you have a bowel movement? Do you struggle with constipation or diarrhea? 
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Do you struggle with anxiety, depression, ADD, or anything similar? If so, what has helped? What have you tried that has not helped? Do you use any tools to manage it?  *
How would you rate your stress level? 1 being "What stress?" and 5 being "I stay stressed ALL the time!"  *
For females, are you still menstruating? If so, describe your cycle  *
Are you breastfeeding, pregnant or trying to conceive?

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Do you have any implants? Pacemaker, heart stents or valves lenses in eyes, metal implants, etc... *
What previous surgeries have you had?  *
When someone starts on their natural healing journey or begins introducing new methods of healing (ex: wanding, detox/cleanses), they may experience what is called a "healing crisis?" This is normal. If you start to feel any symptoms of detox, please reach out. It's important that you focus on hydration and fueling your body every day but especially if you are focused on healing. Please confirm you have read this and understand.  *
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