Intake Form

Personal Information

Please enter your Height and Approximate Weight

Complete to the best of your ability.

Any other information will be discussed in consultation

Do you currently have symptoms you would like to address or are you looking to maintain a healthy lifestyle?

Please list the purpose and medications with dosage if possible.

Please list, with dosage if possible. Include all capsules, powders, tinctures, extracts, teas, peptides, etc.

Breakfast, Lunch, Dinner, Snacks, Patterns, Cravings, Restrictions, Fasting periods, etc

Fast pace work life, stay at home parent, Entrepreneur, etc. Please be as detailed as you are comfortable with

Are you able to exercise regularly, walks after meals, Injuries, past injuries/surgeries that affect your mobility, hobbies, interests, etc.

Are there any past traumas that you feel still effect your daily life? How do you cope with stress? Are there
any major life events that you would like me to know about? Relationship dynamics? Parent/child issues? Support Network?

Do you have any prior diagnoses that I should be aware of, that are not mentioned above? Diseases,
Disorders, Illnesses, Viruses, Issues, Mental Health Concerns, etc.

In order to give you the best care, I like to completely understand my client from all angles of your life. If
there is anything else that you feel would help me further relate to you and your situation, please don't hesitate to tell me more.

Complete to the best of your ability.

By checking this box, I confirm that I voluntarily consent to allow Pirooz Inc. and its authorized wellness practitioners to review the personal, lifestyle, and health-related information I provide. I understand this information is used solely to create personalized wellness guidance and does not constitute medical diagnosis, treatment, or prescription. I acknowledge that I am responsible for consulting a licensed medical professional for any medical concerns. I authorize Pirooz Inc. to securely store and reference this information as part of my wellness planning.

Wellness Disclaimer:

Pirooz Inc. provides holistic wellness education and supplement recommendations based on the information you choose to share. Our practitioners do not provide medical diagnosis, medical treatment, or controlled-act services. Recommendations offered through this platform are for general wellness purposes only and are not a substitute for professional medical care. You should consult your licensed physician for any questions regarding medical conditions, medications, or treatment decisions.