Name
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First Name
Last Name
Email
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Date of Birth
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Phone Number
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What are your main health concerns or symptoms?
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When did these concerns begin?
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What makes these symptoms better or worse?
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Have you been diagnosed with any conditions?
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What are your top 3 goals for working together?
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Describe your current hair and scalp health.
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How often do you wash and what products do you use?
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Do you experience itching, flaking, or scalp sensitivity?
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Yes
No
Occasionally
On a scale of 1–10, how would you rate your daily stress level?
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1-3 Low
4-6 Moderate
7-10 High
How many hours do you typically sleep each night, and how would you describe your sleep quality?
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Caffeine intake (coffee, tea, energy drinks, etc.)
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None
1 cup/day
2 cups/day
3+ cups/day
Do you drink alcohol?
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Never
Occasionally
Weekly
Daily
Do you use tobacco or recreational substances?
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Yes
No
Describe your current exercise routine (type, frequency, or none).
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What type of water do you primarily drink?
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Tap Water
Well Water
Filtered Water
Bottled Water
How many ounces of water do you typically drink per day?
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🌸 DIET & DIGESTION SECTION
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Describe a typical day of eating (breakfast → dinner).
Do you have any food allergies or sensitivities? If so, please list them.
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Do you crave anything regularly (sweet, salty, caffeine, etc.)?
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How would you describe your appetite level?
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Low
Normal
High
Which of the following digestive symptoms do you experience?
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Do you have regular bowel movements?
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Yes
No
Sometimes
🌸 MEDICAL & SUPPLEMENT HISTORY SECTION
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Have you been diagnosed with any current or past medical conditions? If yes, please list them.
Have you had any surgeries or major illnesses? Please include approximate dates if known.
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List all prescription medications you are currently taking (include dosage if known).
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List all supplements, vitamins, minerals, or herbs you are currently taking.
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Are you currently working with another health practitioner (doctor, nutritionist, coach, etc.)?
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Have you had any recent lab testing (bloodwork, HTMA, DUTCH, DNA, etc.)?
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Yes
No
Not Sure
At what age did you have your first period?
Date of last period (if applicable)
Which of the following do you currently experience?
Are you currently using birth control or hormone replacement therapy (HRT)?
Yes
No
Previously
If applicable, describe your main hormonal or menopausal concerns.
🌸 STRESS & EMOTIONAL HEALTH SECTION
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Have you experienced any major life changes or stressors in the past year? (example: new job, loss, illness, move, etc.)
How do you typically cope with stress or unwind? (example: exercise, sleep, hobbies, time alone, etc.)
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Do you experience anxiety, low mood, or brain fog? If yes, how often and in what situations?
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How would you describe your current energy and motivation levels?
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Consistently Good
Fluctuates
Low most days
Very low
🌸 FAMILY HEALTH & GENETIC HISTORY SECTION
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Please check any health conditions that run in your family (parents, siblings, or grandparents).
Do you notice any common lifestyle or stress-related patterns in your family (for example: similar sleep, energy, or emotional patterns)?
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Have you completed any DNA or genetic testing (23&Me, Ancestry, Vicom, etc.)?
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Yes
No
Not sure
If applicable, please share a link or note that you’ll email your DNA raw data file.
Is there anything else you’d like to share about your health journey or goals?
🌸 CLIENT AGREEMENT & CONSENT SECTION
I understand that Elemental Strands LLC provides educational and wellness-based consultations focused on holistic support and lifestyle guidance.
I acknowledge that these services are not intended to diagnose, treat, or cure any medical conditions.
I confirm that the information I have provided is accurate to the best of my knowledge and consent to participate in this wellness program.
Type your full name as your digital signature
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Date
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MM
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