Root Cause Wellness Intake Form
  • Root Cause Wellness Intake Form

  • Vitality Wellness Intake Interview Form and Nutritional Assessment Questionnaire

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  • Format: (000) 000-0000.
  • PROGRAM OVERVIEW
    At Vitality Wellness by Luxe, our goal is to help you better understand your body and support long-term health through a root-cause, functional wellness approach.

    We focus on identifying underlying imbalances that may be contributing to concerns such as:

    Weight gain or difficulty losing weight
    Fatigue or low energy
    Inflammation or gut health issues
    Hormonal imbalance
    Metabolic dysfunction
    Overall health and vitality
    Our approach is centered around supporting the body through foundational health pillars, including:

    Digestion & gut health
    Blood sugar regulation
    Nutrient balance
    Hydration
    Lifestyle habits (sleep, stress, movement)

  • DISCLOSURE

    Vitality Wellness by Luxe provides wellness education, lifestyle guidance, and supportive recommendations.

    We do not diagnose, treat, or cure medical conditions.

    This program is not a substitute for medical care, and no medical diagnosis or prescription will be made through this intake or consultation.

    If you have a medical condition, are pregnant, or are taking medications, you should consult with your licensed healthcare provider before making changes to your health routine.

     

    MEDICAL CARE & RESPONSIBILITY
    You agree to continue care with your primary healthcare provider as appropriate
    You agree to inform your provider of any supplements or changes you implement
    You understand that recommendations may impact how your body responds to medications
    If you experience any adverse symptoms, you should discontinue recommendations and seek appropriate medical care.


    CLIENT RESPONSIBILITY
    Achieving results requires participation and consistency.

    By moving forward, you acknowledge that you are responsible for:

    Following recommendations to the best of your ability
    Communicating changes, concerns, or symptoms
    Making lifestyle adjustments when appropriate
    Understanding that results vary from person to person
    There are no guaranteed outcomes, as each individual responds differently.

    PROGRAM FLEXIBILITY
    Each client is unique. Your plan may be adjusted over time based on your response, progress, and goals.

    Ongoing communication and follow-up are important for optimal results.


    PRIVACY & INFORMATION USE
    Information collected through this intake form and future communication may include:

    Personal identification details
    Health history
    Lifestyle habits
    Symptom reporting


    This information is used to:

    Guide your personalized wellness plan
    Track progress
    Provide appropriate recommendations
    We take reasonable steps to protect your information; however, electronic communication cannot be guaranteed to be completely secure.


    CONSENT
    By signing below, you acknowledge that:

    You have read and understand this information
    You voluntarily choose to participate in this wellness program
    You understand this is not medical treatment
    You agree to the terms outlined above

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