Take the first step in reclaiming your health by filling out this wellness assessment

Thank you for taking the time complete this pre-consultation form. Your responses will help us gain a holistic understanding of your health goals, concerns, and daily habits to make the most of the time during your wellness consultation. Please fill this form out as fully as you can. If you don't have the information or would prefer not to respond, you can simply write "N/A" or leave the question blank. Once you have completed the form, you will receive an email with a link to schedule your free wellness consultation to review your goals and answers.

First Name *

Last Name *

Phone *

Email *

Date of birth

What are your current health goals or challenges?

What do you hope to acheive through our work together?

On a scale of 1-5 (1=low, 5=high), how committed are you in taking the necessary steps to achieve your goals/desires if you had a customized plan that would work for you?

List any diagnosed medical conditions

Do you have any allergies? (medications, food, environmental)

List all medications including purpose (prescription and over-the-counter)

List all supplements and vitamins you take including brand name and dosage

Multivitamin
Omega-3
Probiotics
Herbal Supplements
Other

What are your reasons for taking these supplements?

Do you currently use essential oils? If so, please list brand and oils you use in your daily routine.

Describe your typical diet

Breakfast
Lunch
Dinner
Snacks
Beverages

Do you follow any specific dietary restrictions or preferences? (e.g., vegetarian, vegan, gluten-free)

How many ounces of water do you drink daily?

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

Rate your daily stress level on a scale of 1-10 (1 being low stress and 10 being high stress)

What methods do you use to handle stress or emotional challenges? (e.g., yoga, meditation, hobbies, aromatherapy etc.)

On a scale of 1-10 how would you rate your energy levels throughout the day without stimulants or caffeine? (1=very low energy, 10=sustained energy)

How many days a week do you intentionally exercise? (Go for a walk, yoga, strength training, etc.)

How would you describe the intensity of the exercise you do each week?

I do not exercise

Light

Moderate

Intense

Toxic Load Assessment: List personal care and general home products including brand (put N/A if not applicable)

Cleanser
Moisturizer
Sunscreen
Makeup
Hair products (shampoo, conditioner, styling products)
Deoderant
Body wash
Lotions
Personal Fragrance/perfume
Toothpaste
Laundry detergent
Household cleaners
Room Fragrances (plug-ins, candles)

Please share any additional information relating to your overall health and wellness that was not covered in the questions above that you feel would be important for me to know.

I consent to the collection and use of my health information for the purposes of providing personalized health coaching and support. I understand that this coaching is not intended to diagnose, treat, or prevent any disease or medical condition. I acknowledge that my information will be kept confidential and used only to help guide my wellness journey. Additionally, I consent to receive email notifications, alerts & occasional marketing communication from Claudia Slezak, Root to Rise Wellness LLC

Take the first step in reclaiming your health by filling out this wellness assessment

Copyright © 2025, Claudia Slezak's Account