Roots & Ritual Intake whole-health intake questionnaire Name * First Name Last Name Email * Phone (###) ### #### As Autumn begins to turn towards winter, what are you noticing in your body, mind and spirit? In general, are you someone who tends to be more fluent in doing or being? What messages does your body give you if you need more downtime? Tell me how your nourish yourself, daily? Weekly? Are you an omnivore? Vegetarian? Pescatarian ... Are there any foods that you regularly avoid? Tell me a little about what you eat and how many meals a day? Typical Breakfast? Lunch? Dinner? What is the breakdown of cooked to raw food that you enjoy? Do you shift how you eat depending on the season, mood or energy level? (Or when you are menstruating?) How is your digestion? Burping? Bloating? Acid reflux? Nausea? Pooping 💩 Do you poop every day? Tend toward constipation? Diarrhea? Food in stools? Please share on your daily caffeine intake? Include all caffeinated beverages, including decaf beverages. Do you feel like you need caffeine to 'energize' you? Please share on cannibis use and how it supports you. Are you taking any herbal supplements? If so, how do they support you? Movement and excercise: How many days a week do you move your body? And what types of movement? Do you enjoy it? How do you feel after movement? How are your energy levels throughout the day? Would you like them to be better? How is your mood? Do you find that it fluctuates significantly in a matter of moments? How is your sleep? What time do you go to bed? What time do you rise? Do you feel rested upon waking? Do you use any herb/supplements to support sleep? Have you ever been diagnosed with anemia? if so, when? How were you treated for it? Tell me about your skin? Do you tend toward dryness? Ecxema? Rashes? Tell me about any physical aches or pains that you experience regularly. What makes them feel better? What exacerbates them? Do you tend to feel cold? Cold hands? Cold feet? Do you tend to feel hot? Menstruation: Tell me about your cycle. How many days apart? Do you experience cramping before or after bleeding? Breast tenderness? Low back pain? Bloating? Is there anything else that you would like me to know about you? Are you pregnant or currently trying to conceive? Age: Optional it allows me to have a sense of which stage of life that you are in. Thank you!
