What Does Your Body Need?

Contact Info

First name

Last name

Email

Birthday

Month

Day

Year

Health Info

Wellness Goals (select all that apply)

Womb healing / menstrual balance

Men’s health / prostate support

Fertility & conception support

Postpartum healing

Performance / stamina boost

Nutrient replenishment / mineral deficiencies

Detox / lymphatic reset

More energy / less fatigue

Digestive health

Immune support

Hormonal balance

Respiratory health (asthma, mucus, sinus)

Heart & blood pressure support

Blood cleansing & circulation

Better sleep & nervous system repair

Emotional/spiritual clarity

Mental health & mood stability

Child wellness / Kids’ immune support

Other

Do you have any health conditions or diagnoses we should know about?

Are you currently taking any medication?

Yes

No

Any allergies or sensitivities to herbs?

Lifestyle

Do you currently take herbs, teas, or supplements?

Do you have a current morning or night ritual? (Describe briefly)

Are you open to spiritual practices or rituals (affirmations, journaling, breathwork)?

Yes

No

Healing Preferences

Would you prefer recommendations with minimal detox effects or are you okay with deeper cleansing?

Mild

Deep

Not Sure

Preferred Herbal Form (select all that apply)

Anything else to share?