If you are interested in a specific service, we invite you to complete the form below. We look forward to connecting with you soon!

Are you a current client of Revival Hair Solutions?

Yes

No

First name

Last name

Phone

Email

Personal Goals:

What specific goals do you have for your wellness?

Medical History:

Do you have any diagnosed medical conditions? If so, please list them below:

Have you ever had surgery, hospitalizations, or major illnesses? If so, please list them below:

What medications or supplements are you currently taking?

Have you experienced any sicknesses (beyond the common cold) in the last year?

Yes

No

Nutrition:

Describe a typical day of meals and snacks:

How often do you eat processed foods and/or sugar?

Daily

Occasionally

Rarely

Never

How often do you consume caffeinated beverages?

Daily

Occasionally

Rarely

Never

Have you had food allergies, intolerances, or sensitivities diagnosed?

Energy and Sleep:

How would you rate your energy throughout the day?

Excellent

Good

Fair

Poor

How many hours of sleep do you get per night?

Do you have trouble falling asleep, staying asleep, or waking too early?

Stress and Emotional Health:

How would you describe your daily stress levels?

High

Moderate

Low

Do you experience anxiety, depression, irritability, or mood swings on a daily basis?

Lifestyle Factors:

How much and what type of exercise do you do each week?

Do you smoke, vape, or use recreational drugs?

How often do you consume alcohol?

Daily

Occasionally

Rarely

Never

How much water do you drink daily?

Wellness Goals:

What are your top wellness goals?

Acknowledgment:

I understand this form is for wellness screening purposes only and not for diagnosing or treating medical conditions.

Name

Signature

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Date

Get Started With Rooted Awakenings:

Personal Goals:

Medical History:

Nutrition:

Energy and Sleep:

Stress and Emotional Health:

Lifestyle Factors:

Wellness Goals:

Acknowledgment: