Holistic Intake & Vital Constitution Questionnaire

Client Intake Questionnaire

An invitation to pause, look inward, and mapping the patterns of your biological and cosmic environment.

Personal Coordinates

Name

Preferred Pronoun

Address

Phone

E-mail

Date

II.

General Health & Vigor

Birth Date

Height

Weight

What would you like us to center our focus on during our time together?

With whom do you share a living space? Please include pets.

Previous marriages?

III.

Occupation & Outer Environment

Occupation

Do you like your job?

Is it toxic?

Past jobs

VI.

Sleep, Rest & Circadian Rhythms

Current Sleep Schedule

Ideal Schedule / Chronotype (if known)

Quality of Sleep

Do you wake up refreshed?

Do you experience sleep disruptions?

Difficulty falling asleep Waking in the night Early morning awakening Vivid dreams / Nightmares Night sweats Teeth grinding (Bruxism)

Do you require sleep aids?

VII.

Materia Medica & Current Intake

Prescriptions currently taking?

Drug Name / Dosage

Reason

How Long?

Drug Name / Dosage

Reason

How Long?

Drug Name / Dosage

Reason

How Long?

Drug Name / Dosage

Reason

How Long?

Supplements?

Supplement Name

Reason

How Long?

Supplement Name

Reason

How Long?

Supplement Name

Reason

How Long?

Supplement Name

Reason

How Long?

Supplement Name

Reason

How Long?

Herbs?

Botanical / Formula Name

Reason

How Long?

Botanical / Formula Name

Reason

How Long?

Botanical / Formula Name

Reason

How Long?

Botanical / Formula Name

Reason

How Long?

Botanical / Formula Name

Reason

How Long?

Botanical / Formula Name

Reason

How Long?

IX.

Social, Emotional, & Spiritual Landscape

Relational Balance

What kind of people or environments make you physically exhausted?

Do you feel you have a healthy balance between solitude and social connection right now?

Do you have a reliable network of friends or community that you feel connected to?

Where do you find your sense of belonging outside of work and home?

Do you find solitude to be a space of replenishment, or does it feel challenging?

Energetics & Emotional Space

What emotion do you struggle with most consistently?

What emotion is easiest for you to access?

Where is most of your emotional energy being directed or drained right now?

Does your mind or heart feel crowded now, or is there a sense of spaciousness?

How are you feeling about your current capacity to navigate daily stressors?

Do you feel like you have the space to fully feel and process your emotions right now?

When you sit quietly with yourself, what is the dominant feeling or mood that surfaces?

Stress Adaptation & Coping Profile

Where in your body do you carry stress first?

How do you respond to stress? (Select all that apply)

Withdraw Fight Freeze Overwork Seek connection Intellectualize Dissociate

Do you tend toward control or surrender when overwhelmed? Please elaborate.

Meaning, Cosmos & Deep Ecology

Do you view physical or emotional challenges as having a deeper, non-physical meaning or lesson?

How would you describe your relationship with nature, the cosmos, or a higher power?

What practices, places, or spaces make you feel most connected to something larger than yourself?

Where do you turn, or what do you lean on, when you are looking for meaning in difficult times?

When you think about your life's path, do you view it as something you are solely constructing, or something you are co-creating with a deeper force?

★

Astrological Components (Optional Extensions)

Suggested additions

These optional coordinates assist in mapping your natal astronomical blueprint, natal alignments, and planetary correspondences.

Time of Birth & Location

Climate & Temperature Resonance

What season feels most medicinal to your spirit?

What restores your vitality faster than anything else?

Which do you feel more aligned with?

Sun sign Rising sign Moon sign

Preparation Complete

Review your answers above. You can print the document directly or save it as a digital PDF. After saving, please ATTACH and EMAIL completed form to (click for email): Diana Gross

Wellness and Vital Alchemy

Printing from Preview Frame

Client Intake Questionnaire

Personal Coordinates

General Health & Vigor

Occupation & Outer Environment

Physiological History & Traumatic Imprints

Digestion, Nourishment & Elimination

Sleep, Rest & Circadian Rhythms

Materia Medica & Current Intake

Physical Balance & Somatic Experience

Social, Emotional, & Spiritual Landscape

Astrological Components (Optional Extensions)

Preparation Complete