Sincerely Tiffany Lifestyle & Wellness
Lifestyle & Wellness Assessment
Name
First Name
Last Name
Email (Session summary or wellness recommendations can be sent via email)
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred consultation format:
Phone Call
Video Call
Text
What are you main health or wellness concerns right now? (Share anything you feel is affecting your health or quality of life, whether it's physical, emotional, mental, or related to life circumstances, past or current experiences.)
Emotional Reset - If you’d like support with emotional patterns, select any issues that apply:
Overwhelmed or stressed
Easily irritated or triggered
Sad, heavy, or low
Numb or disconnected
Stuck or unmotivated
Not sure how I’ve been feeling
I’d rather talk about this during the session
I'm not interested in this service right now
Other
List others here:
Physical Wellness / Symptom Support - If you’d like support with physical symptoms, select anything that applies:
Brain fog/Trouble focusing
Sleep issues (trouble falling or staying awake)
Digestive issues (bloating, constipation, diarrhea, heartburn)
Joint or muscle pain
Skin issues (acne, rashes, eczema)
Allergies/Sinus issues
Menstrual or hormonal issues
Frequent colds or infections
Fatigue/Low energy
I’d rather talk about this during the session
I'm not interested in this service right now
Other
List other symptoms you're experiencing here:
Please list any medications you are currently taking & why. (This is to evaluate if medication could be contributing to symptoms and to discuss with your health care provider)
Please list any supplements your are taking and why.
How often do you pay attention to the ingredients in your food, personal care, or household products?
Always
Most of the time
Sometimes
I've never thought about it
How often do you eat processed food or snacks? (Boxed meals, frozen meals, chips, snack cakes, candy)
Multiple times per day
Once per day
Multiple times per week
Occasionally
Rarely
How often do you eat fast food?
Multiple times per day
Once per day
Multiple times per week
Occasionally
Rarely
How often do you exercises?
Daily
3-5 times per week
Occasionally
Rarely
How much sleep do you typically get per day?
less than 5 hours
5 to 6 hours
7 to 8 hours
More than 8 hours
How often do you do things you enjoy? (Hobbies, outdoors, going out with friends)
Daily
Weekly
Occasionally
Rarely
Questions for me
Which areas would you like to focus on? (Select any that apply):
Emotional Reset / Nervous System -Feeling overwhelmed, stressed, or emotionally drained
Household & Pantry Swaps - Choosing healthier options
Ingredient Review - Review of Ingredients in food, household, and personal products
Detox Pathway Guidance - Helping your body clear buildup and feel better by supporting digestion and lymph flow in a simple, realistic way
Herbal Wellness and Natural Remedies - Using herbs and other natural remedies to heal
How did you hear about me?
Please Select
Social Media
Website
Referral
Other
Disclaimer: "I understand this support is focused on lifestyle, wellness, and education and is not a replacement for medical care."
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