Sacred Rouxts Intake

Sacred Rouxts

"Helping Your Body Remember it's Ancestral Wisdom"
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
How can I support you? What is your main concern?
How long have you been dealing with this?
Current Health
Any western diagnosis? Conditions?
Are you taking any supplements, medications or herbs?
Any allergies?
Eating Habits
Typical diet: breakfast, lunch, snacks & dinner.
Do you crave anything? (Sweet, spicy, salty, sour?)
How is your appetite? (Good, poor, always hungry, no interest)
Do you feel bloated, gassy or heavy after eating?
After a meal do you usually feel: full of energy or sluggish & tired ?
Sleep Patterns
How many hours of sleep do you get?
Falling asleep?
Do you wake up feeling rested?
Body Check In
Stress Level
Do you experience pain? If so, what makes it feel better? What makes it worse?
How is your emotional state?
Do you consume:
Check any that apply:
Do you tend to run hot or cold?
Is your skin more dry or oily?
Do you sweat easily?
The Poop Part

Your digestion is one of the best storytellers of your health. Pick the options that fit you best.
How Often do you go?
What is the consistency like?
Any extras you notice?
Color
LADIES (menstrual cycle)
Cycle Regularity
Flow
Color
Pain & Symptoms
Treatment
Preferred method of support
Should be Empty:

Sacred Rouxts