My Flourishing Family
– 14-Day Reset Application & Health Questionnaire
Confidential Wellness Intake Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you currently pregnant or breastfeeding?
Yes
No
Any diagnosed medical conditions?
List any medications or supplements you’re taking.
List any allergies.
What are your top 3 symptoms/concerns?
Your goals for joining the Reset?
Describe your current eating habits.
Have you done a gut/hormone reset before?
Yes
No
How many hours of sleep do you get?
Do you consume any of these regularly?
Caffeine
Sugar
Processed Foods
Alcohol
Current stress level?
Low
Moderate
High
Cultural/dietary needs?
Anything else you'd like to share?
Where did you hear about us?
Facebook
Instagram
Friend
Please confirm you agree with the following terms:
*
I understand this is not medical treatment
I will consult my doctor if I have concerns
I confirm this info is true
I understand this program is voluntary
Signature
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: