Client Intake Form | Wise Intake

Section 1 of 5

About you

Basic information so I can personalise my review for your specific situation.

First name

Last name

Email address

Age

Biological sex

Country / location

Which service did you book?

Section 2 of 5

Your health context

I’m not a doctor and this is not medical advice — but understanding your general health picture helps me flag anything that may be relevant to what you’re taking.

If you have a diagnosed medical condition or are currently taking prescription medication, please mention it below. I’ll flag any supplement interactions to discuss with your doctor — I won’t make medical decisions, but I can raise the right questions.

What are your main health goals right now?

Choose all that apply.

Better energy and reduced fatigue Improved sleep quality Stress management and mental clarity Immune system support Muscle function, recovery, or performance Gut health and digestion Weight management Healthy ageing and longevity Other (describe below)

Any diagnosed health conditions?

Optional. Include only what’s relevant to your supplement use.

Are you currently taking any prescription medication?

Prescription medications (if yes above)

Generic name or brand name is fine. This helps me flag potential interactions.

Any known allergies or intolerances?

Section 3 of 5

Your current supplement stack

This is the most important section. Please be as complete as possible — include everything you’re currently taking, even if you’re not sure it “counts.” The more detail you give, the better my review will be.

For each supplement: the brand name, product name, dose per serving, and how often you take it. If you have the product in front of you, the Supplement Facts panel is the best reference. Photos of labels are also welcome — send them to [email protected] with your name in the subject line.

Supplement stack

Fill in what you know. Leave cells blank if you’re unsure — I’ll note what’s missing.

Product / Brand name	Dose per serving	How often	Why you take it

How long have you been taking your current stack?

Have you noticed any effects — positive or negative — from your current supplements?

How did you choose your current supplements?

Doctor or healthcare professional recommended Online research / articles Social media or influencer recommendation Friend or family recommendation Pharmacy or health store staff suggestion Marketing / advertising Just tried it and kept going

Section 4 of 5

Diet and lifestyle basics

Supplements work differently depending on diet, sleep, and daily habits. This context shapes my recommendations significantly.

How would you describe your diet?

How would you rate the overall quality of your diet?

1 = mostly processed / convenience food, 10 = whole foods, mostly home cooked

5

1 — Poor10 — Excellent

How many hours of sleep do you typically get per night?

How would you rate your current stress levels?

1 = very low stress, 10 = chronically overwhelmed

5

1 — Very low10 — Very high

How physically active are you?

Do you smoke or drink alcohol regularly?

Anything else about your diet or lifestyle that might be relevant?

Section 5 of 5

What you’re hoping to get from this

Helps me focus on what matters most to you and make our session as useful as possible.

What’s the main thing you’re hoping to figure out or resolve?

Is there anything specific you’d like me to focus on or pay particular attention to?

What would make this session feel genuinely worthwhile for you?

Monthly supplement budget (approximate)

Anything else you’d like me to know before we begin?