Parasite Puzzle Personal Guidance INTAKE FORM

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

What prompted you to do the protocol

What are your top 3 concerns?

If we only had time to talk about ONE thing during our first private session, what would you most want my help understanding?

Digestive & Bowel Patterns

Current Health Picture - check any that are of concern

Have you ever completed a parasite protocol before? If yes → which one, approximately when, and what was your experience?

Are you currently taking any medications or supplements? (list)

Have you ever noticed anything unusual in your stool that concerned you?

Have you traveled internationally or lived outside the U.S.?

Have you recently experienced unexplained or persistent changes in bowel habits?

How many times per day do you have a bowel movement?

Other ________________________________________________________

Are you currently pregnant, breastfeeding, trying to conceive, or could you be pregnant?

Do you have any known allergies or sensitivities to medications, foods, herbs or supplements?

If yes please describe

Have you already purchased or started the Foundational Protocol?

Do you currently have pets or frequent contact with animals?

Is there anything you've been embarrassed, hesitant or uncomfortable talking about that you want me to know before we meet? (Trust me, I've probably heard-or seen-it before.)

How often have you taken antibiotics? (How many times/how long ago?)

On a scale of 1–5 how would you rate your......

Rows	Significant concern	Needs improvement	Okay	Good	Excellent
energy
digestion
sleep
mental clarity
emotional well-being
bowel regularity
over-all Wellbeing

Do you drink filtered, tap, bottled, or ionized water?

Other ________________________________________________________

How many glasses a day? (Assuming a glass is 8 oz)

Other ________________________________________________________

How many servings of fruits/vegetables do you eat daily?

Other ________________________________________________________

How much caffeine do you consume?

Other ________________________________________________________

How many hours of sleep do you get on average?

Other ________________________________________________________

Do you have trouble falling asleep or staying asleep?

Do you wake up feeling rested?

Do you spend time outdoors or in natural light daily?

Other ________________________________________________________

Do you smoke or vape?(how often)

I understand this coaching is educational and not a replacement for medical care.

I agree to take personal responsibility for my health decisions.

Disclaimer: I am not a licensed medical doctor, psychologist, or healthcare provider. I am a certified Integrative Health Practitioner and coach. The services, coaching, and tools provided through Mentor With Mikki are educational and supportive in nature. The information on this form, in our sessions, and in any related resources is not intended to diagnose, treat, cure, or prevent any disease.Always consult with your qualified healthcare provider before making changes to your diet, lifestyle, medications, or supplements.By submitting this form, you acknowledge that you are taking full responsibility for your own health decisions and outcomes.You release and hold harmless Mentor With Mikki from any liability related to your participation.

By submitting form you agree to this statement

Privacy Notice - Your privacy matters to me. The information you provide in this Personal Guidance form is strictly confidential. It will only be used by Mentor With Mikki for the purposes of coaching, wellness planning, and communication with you. I will never sell, rent, or share your personal information with third parties. Your data is stored securely through Jotform and associated integrations (e.g., email, scheduling, CRM). You may request to review or delete your information at any time by contacting me directly at mentorwithmikki@gmail.com By submitting this form, you consent to the collection and use of your information as described above.

By submitting form you agree to this statement