Travel Wellness Consulting Services Intake Form

Dr. Dawn's Travel Wellness Consulting Services
Welcome to Dr. Dawn's Travel Wellness Consulting Services

As a Physical Therapist and WITT Wellness Specialist, I help you prepare your body for the unique physical demands of European travel.

This comprehensive intake helps me understand YOUR specific needs, concerns, and travel plans so our consultation sessions can be focused and productive.

Your customized Travel Wellness Toolkit will address:
- Walking preparation and pacing strategies
- Flight comfort and positioning
- Luggage and equipment selection
- Pain prevention and management
- Daily recovery protocols
- Energy management for consecutive touring days
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Trip Destination(s):*
Travel Departure Date:*

MonthDayYear
Date
Return Date:*

MonthDayYear
Date
Type of European Travel:*

River cruiseGuided tour groupIndependent travelMix of guided and independent
Primary Activities Planned:*

City walking toursMuseums and galleriesCastle/ruins explorationHiking/nature walksBeach activitiesReligious sites/pilgrimagesShopping districtsOther:
Current Daily Step Count:*

Less than 2,0002,000-4,0004,000-6,0006,000-8,0008,000-10,000More than 10,000
Longest Recent Walk Without Resting:*

Less than 10 minutes10-20 minutes20-30 minutes30-45 minutes45-60 minutesOver 60 minutes
Current Exercise Routine:*
Standing Tolerance (without significant discomfort)*

Less than 15 minutes15-30 minutes30-45 minutes45-60 minutesOver 60 minutes
Current Pain or Discomfort Areas:*

Lower backHipsKneesFeet/anklesNeckShouldersNone currentlyOther
Past Injuries or Surgeries (last 2 years):*
Experience Preferences: Describe the type of trip or mood you're going for. For example: quiet and nature-focused, romantic and relaxing, or modern and centrally located.*
Current Medical Conditions That Affect Activity:*

ArthritisHeart conditionDiabetesBalance issuesBreathing conditionsChronic fatigueNoneOther
Previous European Travel:*

Never been1-2 trips3-5 trips6+ trips
Biggest Physical Challenges on Past Trips:*
What Limited You Most on Previous Trips?*

Foot painBack painOverall fatigueKnee/hip painCouldn't keep up with groupNot applicable/first tripOther
Top 3 Concerns About This Trip:*
What Would Make This Trip Successful for You?*
Travel Companions:*

Solo travelWith partner/spouseWith family (mixed ages)With friendsTour groupOther
Are you concerned about keeping up with others OR others keeping up with you? If so, explain.*
Current Walking/Athletic Shoes You Own: Please provide specific brands.*
Current Luggage Type:*

Traditional suitcase (2 wheels)Spinner suitcase (4 wheels)Carryon suitcaseBackpackDuffel bagNot sure yetOther
Supportive Equipment You Currently Use:*

Compression socksOrthotics/insolesKnee brace/supportBack supportWalking/trekking polesCaneWalkerNoneOther
One Way Flight Duration (including layovers):*

Under 6 hours6-9 hours9-12 hoursOver 12 hours
Typical Flight Discomfort:*

Lower back painNeck stiffnessSwollen feet/anklesKnee discomfortGeneral stiffnessNone typicallyOther
Services*
prevnext( X )
Travel Wellness ConsultingTravel Wellness Consulting Package - $397Includes:- Two personalized strategy sessions (90 minutes total) via Google Meet- Customized Travel Readiness Toolkit- 30-day email support- Digital resources and guides
$397.00 Quantity

Total

$0.00
*Disclaimer

This consulting service provides education, preparation guidance, and general travel readiness strategies. It does not provide medical advice, diagnosis, or treatment and does not replace care from a licensed healthcare provider.

While the consultant is a licensed physical therapist, this service is offered in an educational and consultative capacity only. Any movement resources shared are general in nature and not prescribed for the treatment of any specific condition. THIS IS NOT A PHYSICAL THERAPY SERVICE.

Clients are responsible for their own travel decisions and should consult appropriate medical or travel professionals as needed.

All purchases are final once the research process begins. Please review your information carefully before submitting to ensure your results match your needs.
Date*

MonthDayYear
Date
I acknowledge that I have read, understand, and agree to the terms of this service.

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Dr. Dawn's Travel Wellness Consulting Services