Daily Roots 1:1 Welcome Questionnaire

~ Daily Balanced Wellness 1:1 Guidance ~

I’m so glad you’ve decided to commit to yourself and your health & well-being. Before we begin I’d like to gather a bit of background information. Please leave any questions blank that you don’t feel comfortable answering, though often the more details the better. [*Required Field]
Full Name*

First NameLast Name
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Date of Birth

MonthDayYear
Age
years
Referred by
What are your main health concerns or challenges?*
When did you first experience these challenges?
How have you dealt with these concerns in the past?
Have you experienced any success with these approaches?
What other types of health practitioners are you currently seeing?
Your current diet could be best characterized as:

low-fatlow-carbhigh-proteinKetoVegetarian/VeganNo special dietOther
Are there any foods that you avoid? Why?
Are there any medications, herbs or supplements that you take regularly?
Your Bowel Function is ..
[Women] Your Cycle is ..
Do you have any medical conditions?
Are you satisfied with the amount & quality of sleep you’re getting? How many hours do you sleep each night on average?
Are you experiencing any stresses or motivational problems?

YesNo
Please rate your readiness for change. [1 Low - 10 High]

12345678910
What are your health goals and aspirations? *
Why?

TImeline for achieving your goal.

	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1+ YEAR
NOW

Who in your life will be supportive of you & your health goals and changes you’re making?
Which Topics are of interest to you right now?

Connecting to Your True NatureFood & HydrationMovement & FlowImmune Boosting StrategiesGut Health & Supportive FoodsDeep Rest & SleepCycles & Rhythms of LifeMindset & IntuitionSelf-CareHerbs & OilsGentle Detox MethodsHealthy KidsOther
1.) CANCELLATIONS

Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance (apart from emergencies) will be forfeited.

2.) LATE ARRIVALS

Each session shall be 50 minutes in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I AGREE TO THE ABOVE TERMS & CONDITIONS!*

YesNo
Signature*

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