Client Intake Form — Wilder Wellness Consulting

The fuller the picture, the better I can help. Answer what you can — every question beyond your name and email is optional, and everything you share stays private between us.

Full & PREFERRED name

Phone

Date of birth

City / where you live

Emergency contact (name & number)

Blood type (if known)

Health history

Take as much room as you need — nothing is too small.

Your health history

A general picture of your health across your life so far.

Current symptoms & concerns

What is going on right now, and how long it has been going on.

Diagnoses (past or present)

Surgeries & procedures

Injuries & accidents

Medications

Include dosage and how long you have been taking them, if comfortable.

Supplements & herbs

Allergies & sensitivities

Your story

Share only what you feel comfortable sharing. All of it stays private.

Your birth story

How you were born, feeding as an infant, anything you have been told.

Childhood health & experiences

Adulthood health & experiences

Trauma & significant stress

Childhood or adult — as much or as little as you wish to share.

Mental & emotional health

Day to day

Digestion & elimination

Sleep

Energy through the day

Hormones & cycle

Pregnancy, birth & postpartum history

How you eat

Movement & exercise

WATER & DRINK DAILY CONSUMPTION

Caffeine, alcohol, nicotine & other substances

Bodywork & preferences

(if applicable)

Bodywork needs

Areas to focus on — or avoid entirely

Pressure preference

Scents & flavors you love or cannot stand

Product preferences

Textures, oils, brands, anything you already use and like.

What would you like to explore during your visit?

Every home and family is different. Select anything you’re curious about!

Wants & wishes

What you would like to work toward

Your wishes — the dream version

Anything else I should know

Questions? Email me at wilderwellnessconsulting@gmail.com