Intake Form
Please complete this form honestly so that /we can best support you
Name
*
First Name
Last Name
Email
beauty@life.com
Dates that you would like to receive the medicine
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Month
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Day
Year
Date
Best Contact Number
-
Area Code
Phone Number
Birth Date
*
Please select a month
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Day
Please select a year
2026
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Year
Place of Birth
*
City and State
Birth Time
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Minutes
AM
PM
AM/PM Option
Describe your top 3 complaints (Ex. depression, weight gain, spiritual connection, anger, trouble sleeping)
How many hours do you sleep on average per night?
What is the quality of your sleep?
Do you wake up often? Do you have trouble falling or staying asleep? Does the smallest movement or noise wake up you?
How many hours do you work everyday?
How many hours do you spend on technology everyday?
Computer, Phone, TV, Airpods
How many hours do you sleep on average per night?
How would you describe your current diet?
Do you follow any specific regimen? How much sugar, salt, processed food, food dyes are you currently eating?
What is your source of drinking water and how much do you drink daily?
Ex: 2 Liters daily of well water, spring water, tap water etc.
What previous surgeries or major health concerns have you had in the last 20 years?
Please share any health scares you may have experienced
Are you missing any organs?
(Tonsils, Appendix, Kidney, Gallbladder etc.)
Do you have any existing blood issues such as high blood pressure, blood clots etc?
Includes Anemia
Are you currently taking any pharmaceutical medications? (including birth control)
List the name and dosage if so, as well as how often you take it
What medicines or vaccines have you taken in the last year?
Include antibiotics
What synthetic chemicals or recreational drugs have you taken in the last 6 months?
Have you had seizures, concussions or serious brain/heart issues in the last 3 years? Please share details.
CEREBRAL Select the frequency of the symptom for each question. (0 = never, 4 = always)
*
Rows
0
1
2
3
4
1. Chronic high stress
2. Inability to handle stress
3. Decreased memory
4. Difficulty to focus
5. Increase in learning difficulty
6. Depression
7. Feeling hopeless, negative thoughts
8. Feeling overwhelmed, anxious for no reason
9. Anxiety
10. Sensitivity to noise
DIGESTION
*
Rows
0
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1. Excess burping after meals
2. Burning in throat or stomach
3. Difficulty moving bowels
4. Diarrhea
5. Bad gas odor
6. Nausea
7. Hemorrhoids
8. Intestinal pain
9. Use of laxatives
10. Swelling
NEURO - MUSCULAR
*
Rows
0
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1. Muscular weakness
2. Muscle spasms
3. Muscle pain
4. Pulsating pain in extremities
5. Strange sensations in skin
6. Weakness, loss of muscle control
7. Sciatica
8. Tremors
9. Uncontrolled spasms
10. Muscles always hurt
INFLAMMATION
*
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0
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1. Chronic joint pain
2. Headaches
3. Chronic constipation
4. Hypertension
5. Eczema or Psoriasis
6. Frequent allergies
7. High cholesterol
8. Rashes on hands or feet
9. Gallstones or gallbladder issues
10. Bitter taste in mouth in morning
CELLULAR ENERGY
*
Rows
0
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1. Chronic anemia
2. Low body temperature
3. Dry Skin
4. Weight Gain
5. Constipation
6. Heart Palpitations
7. Difficulty falling/staying asleep
8. Fatigue
9. Craving sugar and sweets
10. Tired all the time
IMMUNOLOGICAL
*
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0
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1. Frequent diseases
2. Chronic sinusitis or infection
3. Chronic fatigue
4. History of use of antibiotics
5. Chronic candida / yeast infections
6. Inflammation of Tonsils
7. Diarrhea
8. Infection / fungus on toes
9. Dark circles / bags under eyes
10. Cold hands / feet
CIRCULATION
*
Rows
0
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1. Abnormal / irregular pulse
2. Injuries heal slowly
3. Dizziness
4. Headaches
5. Chest pain
6. Abnormal blood pressure
7. Varicose veins
8. Tingling / numbing in extremities
9. Swollen ankles
10. Body is retaining water
HORMONAL
*
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1. Difficulty getting out of bed
2. Dizzy when getting up
3. Thirsty all the time
4. Ringing in ears (high or low tones)
5. Acne
6. Dizziness
7. Hair loss
8. Constant Sweating
9. Frequent Urination
MEN ONLY
Rows
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1. Decreased Sex Drive
2. Lack of physical energy
3. Depression episodes
4. Difficult Urinating
WOMEN ONLY
Rows
0
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2
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4
1. Irregular Periods
2. Hot Flashes
3. Adult Acne
4. Hair thinning
Submit
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