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.Format: (000) 000-0000.
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.*
Non-smokerSmokerOccasional alcohol consumptionRegular alcohol consumptionExercise regularlySedentary lifestyleStress management practices (e.g., meditation, yoga)Other
VegetarianVeganGluten-freeDairy-freeLow-carbPaleoKetoIntermittent fastingNo specific dietOther
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