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Integrated wellness intake form

1. GENERAL INFORMATION

Name:

Age:

Gender:

Country of Residence:

Ethnicity:

If Other, please specify:

2. EMERGENCY CONTACT INFORMATION

Contact Name:

Relationship:

Telephone:

Email:

3. LIFESTYLE & NUTRITION REVIEW

1. How many hours do you usually sleep per night?

< 5 5-6 7-8 > 7-8

2. How would you rate your sleep quality?

Excellent Good Fair Poor

3. Do you wake up refreshed?

Always Often Sometimes Never

4. How often do you experience Food cravings (sugar, caffeine, salty snacks)?

Often Sometimes Rarely Never

5. Average weekly intake: Coffee/tea (cups per week): Alcohol (units per week): Processed food/fast food:

Daily Weekly Sometimes Rare

6. Stress levels (rate 1-10):

4. PHYSICAL ACTIVITY READINESS

Do you currently:

Exercise regularly Walk regularly Practice yoga Participate in strength training

Do you have any limitations affecting:

5. MENTAL WELLBEING CHECK (Over the past month)

Experience	Never	Rarely	Sometimes	Often
Feeling overwhelmed
Difficulty relaxing
Low mood
Lack of motivation
Difficulty concentrating

6. WELLNESS INTERESTS

7. DIETARY REQUIREMENTS

Do you follow any specific diet?

Food allergies (please list):

Foods you dislike or avoid:

8. WOMEN'S HEALTH (OPTIONAL)

Pregnant Menopausal Trying to conceive Perimenopausal Breastfeeding Other

Date of last menstrual period (if applicable):

9. SLEEP DETAILS

Do you experience:

Difficulty falling asleep Snoring Waking during the night Sleep apnoea diagnosis Early morning waking None of the above

What time do you usually go to bed?

What time do you usually wake up?

10. MASSAGE & TREATMENT SAFETY

Please provide any additional information we should be aware of:

11. GOALS & EXPECTATIONS

What is the primary reason for your stay? (tick all that apply):

Relaxation Spiritual development Stress reduction Health improvement Burnout recovery Digital detox Better sleep Personal growth Other

What would make your stay successful for you?

12. CONSENT & ACKNOWLEDGEMENT

I understand that Sati Wellness provides wellness, educational, and lifestyle services and does not provide medical diagnosis or treatment.
I confirm that the information provided is true and complete to the best of my knowledge.
I understand that my information is kept confidential, used only to deliver safe and personalised wellness care, shared only with authorised staff, and may be used in de-identified form for service improvement and research.

I agree to the above.

Signature (Type Name):

Date: