Client Intake Form

SLO WELLNESS - CLIENT INTAKE, TIMELINE & 5-DAY FOOD DIARY
PERSONAL INFORMATION
Full Name
Date of Birth

MonthDayYear
Date
Sex
Age
Email Address
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Emergency Contact Name Number
HEALTH BACKGROUND & CURRENT CARE

This helps me understand your current health picture, what you’re navigating and who is supporting you right now. Please share whatever feels relevant.
What are your primary health concerns right now?
Have your been given any diagnosis (past or present)?
Are you currently taking any medications?
Are you currently taking any supplements?
Include brand if you know it.
Do you have any allergies or sensitivities (food, medications, environmental or topical)?
If yes, list anything relevant.
Are you currently seeing any specialists or practitioners (medical or holistic)?
Has anything recently changed in your health or lifestyle that feels important to mention?
DIGESTIVE HEALTH

Your digestion function offers key insights into your cellular energy and recovery. Please check any that apply.
Please check any/all that apply to you.

Other
STOOL FORM (Bristol Scale)

Please choose the description that most closely matches your usual stool form.
How often a day are you eliminating stool?
LIFESTYLE & ENVIRONMENT

Your daily habits and environment play a big role in cellular energy and recovery. These questions give insight into your lifestyle and environment.
What type of water do you drink? (BRITA, RO, distilled, spring water, other, etc.)
Exercise routine: type-frequency-intensity.
Sleep quality (describe quality and times you go to bed)
Stress level: Describe
Occupation? How do you feel about your job?
SUNLIGHT, OUTDOOR TIME & GROUNDING

These questions help me to understand your natural light exposure, circadian rhythm and connection to the outdoors - all of which affect mitochondrial health.
How much natural sunlight do you get on most days?
Do you get morning sunlight or see the sunset?
How often do you spend time outdoors (walking, sitting, grounding)?
How much screen exposure do you have during the day? (TV, Computer and mobile phone)
Do you currently use any blue-light filters, nighttime screen settings or incandescent lighting?
FEMALE HEALTH

Women’s Health & Hormonal Wellbeing (current or past symptoms - post menopausal). These questions help me understand hormonal patterns, stress responses and cycle health. Skip anything that doesn’t apply.
When was the first day of your last period?
What is your typical cycle length?
Do you experience any symptoms around ovulation, before or during your period? If yes, what do you notice?
Have you used hormonal birth control in the past or currently? If yes, what type and for how long?
How do you currently cope with stress? What types of things tend to feel overwhelming for you?
MALE HEALTH

These questions help me understand hormonal, metabolic and stress related patterns. Skip anything that doesn’t apply.
Do you experience any changes in energy, stamina or motivation?
Have you noticed any changes in libido or sexual health?
Do you experience any urinary changes (frequency, flow or urgency)?
Have your ever had your testosterone levels checked?
Do you experience stress, irritability/mood changes or sleep issues that feel new or unusual?
This information is to share how you feel you are managing stress in work and home life.
TIMELINE OF EVENTS

Please list major health events from birth onward: Infections, emotional stressors, injuries, surgeries, diagnosis or major life shifts in CHRONOLOGICAL order - earliest at the top. Your health story matters. Please share what feels significant.
Birth/Early Childhood (0-6 years)
Write anything meaningful from birth through early childhood
Childhood (7-12 years)
Important events, symptoms, moves, stressors, illnesses or anything that stands out from childhood.
Adolescence/Teen Years (13-19 years)
Health shifts, emotional seasons, school stress, injuries, infections, alcohol or drug use or other events during your teen years.
Early Adulthood (20s-30s)
Relationships, pregnancies, miscarriages, major life shifts, symptoms, diagnosis, changes in health, emotional stressors or significant events during this time.
Mid Adulthood (40s-50s)
Career changes, relationship shifts, symptoms, stress periods, infections, emotional seasons or any major life events during this time.
Later Adulthood (60s and beyond)
If this section does not apply to you, please feel free to skip.
Past 12-18 Months
Infections, symptoms, stressors, emotional events, major life changes, flareups, improvements or anything significant in the last 12-18 months.
Anything Else You Feel Is Important
Any final notes, events, patterns or experiences that you feel has shaped your health or wellbeing.
FIVE-DAY FOOD DIARY

There is no “perfect” here - just your real daily rhythm. This helps me see how your body is responding and where support is needed. This is simply a snapshot.

Day 1

Rows	Time	Food & Drinks	Symptoms/ Energy	Notes ?
Breakfast
Lunch
Dinner
Snacks
Supplements

Day 2

Rows	Time	Food & Drinks	Symptoms/ Energy	Notes ?
Breakfast
Lunch
Dinner
Snacks
Supplements

Day 3

Rows	Time	Food & Drinks	Symptoms/ Energy	Notes ?
Breakfast
Lunch
Dinner
Snacks
Supplements

Day 4

Rows	Time	Food & Drinks	Symptoms/ Energy	Notes ?
Breakfast
Lunch
Dinner
Snacks
Supplements

Day 5

Rows	Time	Food & Drinks	Symptoms/ Energy	Notes ?
Breakfast
Lunch
Dinner
Snacks
Supplements

Thank you for taking the time to record these details. This 5-day diary helps me to understand your patterns, rhythms, digestion, cravings, energy needs and how your body responds across your days.
YOUR DESIRED OUTCOMES

Your body heals in phases. This is a space to share what meaningful improvement would look like in your body and your life. This helps shape a roadmap that aligns with your priorities, lifestyle and pace your body needs. Think about what 20-30% better would feel like and how that would show in your day-to-day life.
What would progress look like for you in 6-12 months?
What do you feel you need the most support with right now?
There are no wrong answers here. This is simply a space to share what would feel supportive, helpful or grounding for you in your experience with me.
How committed do your feel your are to your wellness journey right now?
This is just to understand what kind of support you need - not to judge or evaluate your commitment.
CONSENT & UNDERSTANDING

This helps us work together clearly, respectfully, and within the right scope of practice.
I understand that the services I receive from Shalla O’Keefe and SLO Wellness are meant to support my wellbeing through education, nutritional awareness, lifestyle guidance and personalized health insights.

I understand that Shalla is not a medical doctor, nurse, pharmacist, dietitian or licensed healthcare provider, and that she does not diagnose, treat or cure medical conditions.

The information shared is for educational and informational purposes only and is not a substitute for medical care.

I acknowledge that:
- I am responsible for my own health decisions.
- Any changes to medications, supplements or medical treatments must be discussed with my physician or primary healthcare provider.
- I will seek medical attention for any symptoms or concerns requiring a medical evaluation.
- Nutrition, lifestyle and supplement guidance may influence how I feel, and I will contact my doctor if I experience unexpected or concerning changes.
I understand that all guidance offered reflects education, research and professional training in holistic nutrition and wellness—not medical advice.

I agree not to interpret any information from Shalla O’Keefe or SLO Wellness as medical opinion or medical instruction.

By signing, I release Shalla O’Keefe and SLO Wellness from any liability related to how I choose to use or apply the information provided.

I understand I am participating voluntarily and may withdraw at any time.
Client Signature
Date

MonthDayYear
Date
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SLO WELLNESS - CLIENT INTAKE, TIMELINE & 5-DAY FOOD DIARY

PERSONAL INFORMATION

HEALTH BACKGROUND & CURRENT CARE

DIGESTIVE HEALTH

STOOL FORM (Bristol Scale)

LIFESTYLE & ENVIRONMENT

SUNLIGHT, OUTDOOR TIME & GROUNDING

FEMALE HEALTH

MALE HEALTH

TIMELINE OF EVENTS

FIVE-DAY FOOD DIARY

YOUR DESIRED OUTCOMES

CONSENT & UNDERSTANDING