Feminine Vitality Ritual — Wellness Form

Section 1 — Client Information

Full name *

Date of birth *

Phone number

Email

Preferred appointment date

How did you hear about us?

Section 2 — General Wellness

How would you describe your overall health?

Excellent Good Fair Poor / Needs attention

Section 3 — Feminine Wellness Goals

What are your current wellness goals? Select all that apply.

Other (optional)

Section 4 — Medical Awareness

Are you currently pregnant?

Yes No Maybe

When was your last menstrual cycle?

Have you had any recent procedures or infections?

Yes No

Are you on any medications? (list if applicable)

Section 5 — Lifestyle

How would you describe your current stress levels?

Very balanced and energized Mostly balanced with occasional stress Experiencing moderate stress or tension Frequently overwhelmed or depleted In need of deeper support and restoration

How would you describe your current energy?

Consistently energized Generally stable with occasional fatigue Frequently tired or depleted Struggling with low energy most days Experiencing burnout or exhaustion

How are you currently sleeping?

Deep, restful sleep consistently Mostly restful with occasional disruption Light or interrupted sleep Difficulty falling or staying asleep I rarely feel fully rested

How often do you feel emotionally overwhelmed, overstimulated, or mentally fatigued?

Do you experience any of the following on a regular basis? (check all that apply)

Typical daily water intake:

Do you feel your current nutrition supports your energy, mood, and overall well-being?

If you could improve one area of your overall well-being right now, what would it be?

Section 6 — Session Preferences

Are you comfortable with an in-home session?

Yes No Maybe

Anything you'd like me to know to make your experience more comfortable? (optional)

Is there anything else you'd like to share before we meet? (optional)

Section 7 — Consent

Referral code (optional)

If you were referred by a partner or practitioner, enter their code here.

🌸 Feminine Vitality Ritual

Referral code (optional)

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