Client Intake Form for Nutrition and Holistic Menopause Care

Loressence Wellness, LLC

Please provide detailed information to help us offer you personalized nutrition and health recommendations.
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Date of Birth*

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Please describe your overall health history, including any chronic conditions, past surgeries, or significant illnesses.*
Lifestyle Habits (Please select all that apply)*

Non-smokerSmokerOccasional alcohol consumptionRegular alcohol consumptionExercise regularlySedentary lifestyleStress management practices (e.g., meditation, yoga)Other
Dietary Preferences and Restrictions (Please select all that apply)*

VegetarianVeganGluten-freeDairy-freeLow-carbPaleoKetoIntermittent fastingNo specific dietOther
Menopause-related Symptoms (Please select all that apply)*

Hot flashesNight sweatsMood swingsSleep disturbancesWeight gainDecreased libidoVaginal drynessIrregular periodsOther
Please list any specific health concerns or symptoms not covered above.
Current Medications (Please include dosage and frequency)*
Allergies (Please specify any allergies or sensitivities)*
What are your primary goals for your health and wellness?*
Legal Clauses
1. Consent to Treatment: By submitting this form, you acknowledge and consent to the services provided by Loressence Wellness, LLC, including nutrition, holistic health, and menopause care.*
2. Privacy and Confidentiality: Your personal and health information will be protected and used in accordance with applicable laws, including HIPAA compliance where relevant. We are committed to maintaining your confidentiality.*
3. Disclaimer: The services provided by Loressence Wellness, LLC are not a substitute for medical advice, diagnosis, or treatment. Please consult your healthcare provider for medical concerns.*
4. Cancellation and Refund Policy: Please provide at least 24 hours notice for appointment cancellations. Refunds are subject to our discretion and policies.*
5. Liability Waiver: By participating in our programs and services, you agree to release Loressence Wellness, LLC from any liability related to outcomes from the advice or services provided.*
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Loressence Wellness, LLC

Legal Clauses