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Client Intake Form
“Data submitted by this form will be used by Honour The Temple, LLC and no other entity or individual.”
Name: *
Address: *
Phone *
Email *
Date of Birth *
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What are your top three mind-body health & wellness goals? *
Do you have any previous experience with Ayurveda or Nutritional/Lifestyle Counselling? Yes or No? If yes, please list: *
What are hoping to learn, better understand and/or experience through my services? *
What health management tools or practices do you already use? (ie. taking supplements, listening to guided meditation or motivational podcasts, making healthy meals for yourself, reducing artificial sugars…) *
Amidst the pace of day-to-day life, what do you find yourself looking forward to? What currently brings you joy? Please describe: *
In your own words, what does “optimal health” feel like? Look like? Please describe: *
Aside from regular check-ups? Have you been under the care of a licensed health care provider in the past year? Yes No If yes, for what reasons? (Please include diagnosis and duration.) *
How have your health problems progressed since they began? *
Please list current prescription and nonprescription medications (including vitamins & herbs): If yes, for what reasons? (Please include diagnosis and duration.) *
Is there any past medical history (i.e., illness, physical trauma, emotional stress, addiction) that will help to understand your current health condition and goals? *
Have you experienced any major trauma, loss or life changing significant events? *
Do you have any known allergies or intolerances? Yes No If yes, please list: *
How would you rate your energy level in general? *
During the day do you feel: *
Please describe the nature of your job including: general role/responsibilities; hours spent in the office, time spent working once home and on the weekends; and any work related stress: *
In general, how often do you feel stressed, rushed and/or behind? *
How regularly do you follow your ideal routine? *
Is the idea of a routine: *
How often do you exercise? *
At what time of day do you typically exercise?
Please specify type of exercise, duration & intensity:
What do you currently do or would like to do to alleviate stress? Please describe *
At what time do you prefer to wake up? *
At what time do you usually go to bed? *
What time to do turn off screens? *
Do you have a different sleep schedule on weekends? If so, on free days what time do you go to bed? What time do you wake up? *
How do you generally feel upon waking? *
Please mark all that describe the your sleep quality: *
Required
On nights when you stay up later than your ideal, it’s usually because: *
When you have a bad night’s sleep, your biggest challenge is that you feel: *
What is your level of stress presently in your life (10=highest) *
Lowest
Highest
Have you worked with a counsellor, psychologist or psychiatrist?
Clear selection
At what time do you eat your first meal of the day? *
Which is your biggest meal? *
At what time do you eat your final meal of the day? *
Time
:
How much of your daily intake occurs after 6pm? *
How’s your digestion? *
If applicable, please describe any digestive discomfort you experience:
How much water do you drink per day? *
How often do you drink caffeine? *
Are there particular foods that cause discomfort when you eat them? Yes or No? If yes, please list: *
What do you eat on a typical weekday? *
How is it different on weekends? (Describe) *
What type of diet do you currently follow *
What are some of your favorite foods and how often do you eat them? *
Do you experience any symptoms if you miss a meal? Explain *
Do you avoid certain foods? Please Explain *
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