================================================================================ VITA — CLIENT INTAKE FORM Filled in by VITA during the session as the client talks ================================================================================ SESSION DATE: _______________ SESSION TYPE: [ ] Free Consultation [ ] Paid Follow-Up [ ] Check-In ================================================================================ CLIENT DETAILS ================================================================================ First Name: _______________ Full Name: _______________ Email: _______________ Phone: _______________ Age: _______________ Gender: _______________ How they found VITA: _______________ ================================================================================ REASON FOR VISIT ================================================================================ Why did they come today? (in their words): Main concern: _______________ How long has this been going on: _______________ What have they tried so far: ================================================================================ SLEEP ================================================================================ How would they describe their sleep: _______________ Hours per night: _______________ Trouble falling asleep: [ ] Yes [ ] No Wake during the night: [ ] Yes [ ] No What time: _______________ Wake up feeling rested: [ ] Yes [ ] No Sleep environment (dark, cool, screens): _______________ Sleep aids used (melatonin, apps, etc): _______________ Sleep quality (1-5): _______________ ================================================================================ ENERGY ================================================================================ Morning energy: [ ] Good [ ] OK [ ] Low Afternoon energy: [ ] Good [ ] OK [ ] Low [ ] Crashes Evening energy: [ ] Good [ ] OK [ ] Low [ ] Second wind Relies on caffeine: [ ] Yes [ ] No How much: _______________ Energy level (1-5): _______________ ================================================================================ STRESS ================================================================================ Main sources of stress: _______________ How stress shows up (body, mood, sleep): _______________ Coping methods: _______________ Physical symptoms (jaw, shoulders, gut, headaches): _______________ Stress level (1-5): _______________ ================================================================================ DIET & NUTRITION ================================================================================ What do they eat for breakfast: _______________ Typical lunch: _______________ Typical dinner: _______________ Snacking habits: _______________ Water intake per day: _______________ Alcohol: [ ] None [ ] Occasional [ ] Regular How much: _______________ Food sensitivities or allergies: _______________ Do they cook or eat out mostly: _______________ Any diets tried recently: _______________ Currently following a diet: [ ] No [ ] Keto [ ] Mediterranean [ ] Fasting [ ] Vegan [ ] Other: _______________ How is their digestion: _______________ Bloating or gut issues: [ ] Yes [ ] No Details: _______________ ================================================================================ EXERCISE & MOVEMENT ================================================================================ Current exercise: _______________ How often: _______________ Type (walking, gym, running, yoga, none): _______________ Enjoys it or forces it: _______________ ================================================================================ DEVICES & TRACKING ================================================================================ Uses a smartwatch: [ ] Yes [ ] No Which one: _______________ Uses a sleep tracker: [ ] Yes [ ] No Which one: _______________ Uses any health apps: [ ] Yes [ ] No Which ones: _______________ Tracks food intake: [ ] Yes [ ] No Open to using a device if recommended: [ ] Yes [ ] No [ ] Maybe ================================================================================ SUPPLEMENTS — CURRENTLY TAKING ================================================================================ Supplement 1: _______________ Dose: _______________ Supplement 2: _______________ Dose: _______________ Supplement 3: _______________ Dose: _______________ Supplement 4: _______________ Dose: _______________ Supplement 5: _______________ Dose: _______________ (add more as needed) How long have they been taking these: _______________ Noticed any benefit: _______________ ================================================================================ MEDICATIONS & CONDITIONS (SAFETY — MUST COMPLETE) ================================================================================ Current medications: _______________ Doses: _______________ EXISTING CONDITIONS (tick all that apply): [ ] Diabetes (Type 1 / Type 2) [ ] Heart condition Details: _______________ [ ] High blood pressure [ ] Low blood pressure [ ] Thyroid (hyper / hypo) [ ] Autoimmune condition Which: _______________ [ ] Kidney issues [ ] Liver issues [ ] Epilepsy / seizures [ ] Cancer (current or history) [ ] Chronic pain [ ] None of the above Mental health: [ ] Anxiety [ ] Depression [ ] PTSD [ ] None [ ] Other: _______________ Currently seeing a therapist or psychologist: [ ] Yes [ ] No Allergies (food, medication, supplements): _______________ Under a doctor's care for anything: [ ] Yes [ ] No What: _______________ Family health history (heart disease, diabetes, cancer, dementia): _______________ Smoking / vaping: [ ] No [ ] Yes How much: _______________ Pregnant or breastfeeding: [ ] Yes [ ] No [ ] N/A ================================================================================ LIFESTYLE & ENVIRONMENT ================================================================================ Occupation: _______________ Desk job / active job / shift work: _______________ Daily screen time (hours): _______________ Time spent outdoors daily: _______________ ================================================================================ BLOOD WORK & TESTING ================================================================================ Had blood work done recently: [ ] Yes [ ] No When: _______________ Tests done (tick if known): [ ] Vitamin D [ ] B12 [ ] Iron / Ferritin [ ] Thyroid (TSH, T3, T4) [ ] CRP (inflammation) [ ] Cholesterol [ ] Blood sugar / HbA1c [ ] Homocysteine Results known: [ ] Yes [ ] No Notes: _______________ ================================================================================ GOALS & BUDGET ================================================================================ Goals timeline — when do they want to see results: _______________ Budget for supplements: [ ] Minimal [ ] Moderate [ ] Happy to invest Open to lifestyle changes: [ ] Yes [ ] Somewhat [ ] Prefer supplements only ================================================================================ VITA'S OBSERVATIONS ================================================================================ What stood out most: Red flags (needs doctor, serious condition, medication interactions): Quick wins (easy things to fix first): Client motivation level (1-5): _______________ Client knowledge level (1-5): _______________ ================================================================================ RECOMMENDED JOURNEY ================================================================================ Primary: [ ] Sleep [ ] Brain [ ] Energy [ ] Stress [ ] Longevity [ ] Immunity [ ] Gut [ ] Foundation Secondary: [ ] Sleep [ ] Brain [ ] Energy [ ] Stress [ ] Longevity [ ] Immunity [ ] Gut [ ] Foundation Why this journey: ================================================================================ SMALL INSIGHT GIVEN (Phase 3) ================================================================================ What was shared: ================================================================================ NEXT STEPS ================================================================================ Did they book a paid session: [ ] Yes [ ] No If no — reason: _______________ Next session date: _______________ Action items for VITA before next session: Notes for next session: ================================================================================ DISCLAIMER ACKNOWLEDGED ================================================================================ Client verbally confirmed VITA is a coach, not a doctor: [ ] Yes [ ] No Date: _______________ ================================================================================