Wellness Intake Form

Rouz n Retreat

Wellness Intake Form

Please complete this form before your scheduled consultation. Your responses allow the practitioner to review your health background in advance so your session time is focused and productive.

Session information

Which session did you book? *

Personal information

First name *

Last name *

Age *

Biological sex

Email address *

Phone number

Best time to reach you

Health history

What is your primary health concern? *

How long have you been experiencing this concern?

Any diagnosed health conditions? Please list them.

Current prescription medications (name and dosage if known)

Current supplements or herbal products

Allergies (food, environmental, herbal, or other) *

Lifestyle

How would you describe your current diet?

Sleep quality

Daily stress level

Exercise frequency

Daily water intake

Goals & expectations

What would you like to accomplish from this consultation? *

What have you already tried for this concern?

Anything else you want the practitioner to know before your session?

The information you provide is used solely to prepare for your consultation with Rouz n Retreat. It is not shared with third parties and does not constitute a medical record. This form is not a substitute for care from a licensed medical provider.

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Wellness Intake Form

Wellness Intake Form