Intake Form – Strong Wellness and Vitality LLC

Strong Wellness & Vitality LLC

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Client Intake Form – Juicing Program

Client Information

Full Name

Phone Number

Date of Birth

Health & Wellness Goals

What are your primary health goals for starting a juicing program?

Weight loss Detox/Cleansing Increased energy Improved digestion Immune support

Do you have any current health conditions or diagnoses?

Are you currently taking any medications or supplements?

Yes No

Medications or Supplements

Do you have any food allergies or sensitivities?

Yes No

Food allergies or sensitivities

How would you describe your current eating habits?

Balanced High in processed foods Vegetarian/Vegan Low-carb/Keto Other

Other Eating Habits

How many servings of fruits and vegetables do you typically consume daily?

0–1 2–3 4–5 6+

How much water do you drink daily?

Less than 4 cups 4–6 cups 7–8 cups More than 8 cups

What is your current level of physical activity?

None Light (1–2 days/week) Moderate (3–4 days/week) Active (5+ days/week)

Have you ever tried juicing before?

Yes No

Juicing Experience

What challenges do you anticipate with starting a juicing routine?

Is there anything else you would like us to know to better support your wellness journey?

Acknowledgment & Consent

I understand that the juicing program offered by Strong Wellness & Vitality LLC is not intended to diagnose, treat, cure, or prevent any disease. I acknowledge that I am responsible for consulting with a healthcare provider regarding my health conditions.

Disclaimer

This content is for informational purposes only and is not intended as medical advice. Please consult a healthcare professional before making lifestyle changes.

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