Vitality Wellness Discovery Call Intake Form

Vitality Wellness Discovery Call Intake Form
Before You Begin

This is a brief intake form for your Vitality Wellness Discovery Call Consultation. Please complete as thoroughly as possible at least 24 hours prior to your scheduled Discovery Call so we can make the most of your time.

This form is designed to help us understand your current concerns, health history, and goals so we can determine if this program is the right fit for you.

Some questions may not apply to you—please answer what you can and skip anything that does not.

Please note:

This consultation is educational and wellness-based in nature.
It does not establish a provider-patient relationship.
Recommendations, if provided, are individualized and may include lifestyle, wellness, and optional clinical guidance.
All information submitted is kept confidential.

We recommend allowing approximately 10–15 minutes to complete this form.

Please reach out to us directly at 260.269.5893 or via email at luxeaestheticsandwellness4u@gmail.com with any questions prior to your appointment.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth*

MonthDayYear
Date
Primary Concerns
What are your main health concerns that led you to schedule this consultation?*
Has anything helped you feel better?
Has anything made your symptoms worse?
Anything important you want me to know before your consultation?
Goals
What would you say you are most interested in?*

Are my symptoms connected?How much will this cost?How does your program work?Do you offer virtual visits?Can I use testing that I have already had done?Do you work with hormone issues?Can you help with gut issues?Do you work with children?
If there was ONE question you want answered about your health, what would it be?*
Symptoms
Select all symptoms that apply to you:*

Digestive issuesFatigueBrain FogHormone imbalanceSugar cravingsInflammationPoor sleepMood swings / AnxietySkin issues/ rashesWeight GainDecreased libido
Quality of Life

Rate how things have been going for you for the following (0–10 scale)0 = Poor | 5 = Average | 10 = Excellent
Overall Health*

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10

1 is Poor, 10 is Excellent
Energy Levels*

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10

1 is Poor, 10 is Excellent
Sleep Quality*

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10

1 is Poor, 10 is Excellent
Stress Levels*

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1 is Poor, 10 is Excellent
Gut Health Snap Shot
Do you have any of the following?*

Digestive issues (bloating, gas, constipation, or diarrhea) antibiotic useFrequent sugar or carb cravings?Low energyDaily fatigueBrain fogDifficulty concentratingPoor sleep qualityMood swings/ Anxiety/ IrritabilityHormonal imbalanceMenstruation cycle issuesSkin concerns (acne, rashes, exzema)Frequent illnessSlow reccoveryHistory of frequent antibiotic use
Program Interest
What best describes your interest?*

Ready to move forwardWant more infoJust exploring
Are you open to a structured wellness program?*

YESNOMAYBE
Consent
Therapeutic Partnership Acknowledgment & Consent

At Luxe Vitality Wellness, I understand that care is delivered through a collaborative partnership.

I acknowledge that this program is not a one-size-fits-all approach. My care will be personalized based on my individual symptoms, lifestyle, goals, and readiness for change.

I understand successful outcomes are achieved through a combination of:

Lifestyle factors including nutrition, sleep, stress management, and movement

Targeted wellness support, which may include lab recommendations, supplementation, and clinical guidance

I acknowledge that meaningful results require my active participation, consistency, and follow-through with recommended strategies.

I understand that no specific results are guaranteed, and that outcomes vary based on individual factors and adherence to the plan.

By signing below, I confirm that I have read and understand the Therapeutic Partnership model and agree to actively participate in my care.
Signature*
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Vitality Wellness Discovery Call Intake Form

Primary Concerns

Goals

Symptoms

Quality of Life

Gut Health Snap Shot

Program Interest

Consent