🌿 Muladhara Wellness

New Client Intake Form

👤 A. Personal Details

Upload a clear photo for your profile. Please keep the file under 5MB (JPG or PNG).

Enter your name as you'd like it to appear on your wellness records.

Select the gender you identify with for mindful health recommendations.

Helps us understand your current life phase and wellness needs.

For important updates about sessions and wellness plans.

For detailed updates, digital wellness reports, and assignments.

Helps assess geographical factors that may influence your health profile.

Essential for syncing session timings and digital wellness routines.

Select all that apply to help us find the best time slot for you.

🧍‍♂️ B. Current Lifestyle Snapshot

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Select any foods you avoid and provide a reason. This helps us create personalized diet plans.

🧠 C. Health & Wellness Background

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Select any conditions you have or have had. This ensures your wellness plan is safe and effective. All information is strictly confidential.

🫀 Cardiovascular & Endocrine Health

🌬️ Respiratory & Immunity

🧠 Neurological & Sleep Health

🦴 Musculoskeletal & Injury History

🧘‍♀️ Mental & Emotional Health

🩺 Digestive & Organ Health

🌸 Women’s Health

🔍 Other Health Considerations

🎯 D. Wellness Goals & Preferences

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Select all that apply. This helps us tailor your journey.

Select areas you are interested in exploring. You can choose as many as you like.

🧘‍♂️ Core Yogic & Physical Wellness
🕉️ Energy, Mantra, and Subtle Body Work
🌿 Nature & Elemental Therapies
🧬 Detox, Diet & Naturopathic Support
🧠 Emotional, Mental & Spiritual Healing
✨ Spiritual & Transformational
👶 Specialized Support Tracks
⚙️ Integrative / Scientific / Global Methods
📝 Custom Combination

✅ E. Consent & Declaration