Personalized Wellness Intake Form

Personalized Wellness Intake Form

Initial Client Questionnaire
This short, guided questionnaire helps us understand your goals, lifestyle, and wellness priorities.

Medical History and Safety

To ensure there are no contradictions with your current regimen.
1. Current Medications: Please list all prescription drugs you are currently taking.
2. Current Supplements: What vitamins, minerals, or herbs are you already taking?

Medical History and Safety
3. Allergies: Do you have any known allergies (e.g., shellfish, soy, dairy, gluten)?

Lifestyle & Environment
Dietary Preferences:
Dietary Style: (e.g., Vegan, Keto, Paleo, Standard American, Intermittent Fasting)
Daily Energy Levels: On a scale of 1-10, how is your energy level at…
Morning:
Afternoon (3 PM):
Evening:
Sleep Patterns:
How many hours do you average a night?

Lifestyle & Environment
Do you have trouble falling asleep or staying asleep?
Stress Levels:
How would you rate your daily stress (1-10)?
Movement:
How many days per week do you engage in 30+ minutes of physical activity?
*Why we ask this: We view supplements as "gap-fillers." If you are vegan, you may need B12; if you are under high stress, your body depletes Magnesium and Vitamin C much faster. Your habits reveal your unique nutrient needs.

Symptoms
Check any symptoms you experience regularly:

Digestion: Bloating, gas, indigestion, irregular bowel movements.Cognitive: Brain fog, forgetfulness, lack of motivation.Physical: Joint pain, muscle aches, brittle hair/nails, skin breakouts.Mood: Irritability, low mood, "wired but tired" feeling.Other

Logistics & Preferences

The best protocol is the one the customer actually follows.
Delivery Preference:

CapsulesTabletsPowdersLiquids/TincturesGummies

Logistics & Preferences
Commitment: How many times a day are you willing to take supplements?

Once and done3x a day with mealsMorning and eveningWhatever it takes
*Why we ask this: If you hate swallowing large pills or have a busy morning schedule, a protocol requiring 5 capsules twice a day will fail. We tailor the delivery method to your lifestyle - an approach that drives consistency and real progress.
Fees

"Give me the essentials only.""I want a comprehensive, premium routine."

Final Thoughts
Is there anything else you'd like us to know about your wellness goals or challenges?
Paradise Organics - Personalized Wellness Protocol

Important Information
We provide nutritional support and education. We do not diagnose or treat medical conditions.

This questionnaire is for wellness and educational purposes only and does not replace medical advice. Please consult your healthcare provider before beginning any new supplement regimen.
Privacy Disclaimer: We value your privacy and are committed to protecting your personal information. Any data you provide will be used solely for the purposes stated at the time of collection and will not be shared with third parties without your consent.
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Primary Health Objectives