Foundations Intake | Restore Your Precious Body

Welcome to the Foundations Program.
Our aim is to deeply understand your current journey and how to best support your precious body.
By taking a moment to thoughtfully answer these questions you're sharing the data needed for us to build a mental map of your body which will continue to be filled in as your body progresses. This helps us most effectively combine what a body needs with what your body is asking for.
Thank you.

Personal Information

Today's Date

First Name

Last Name

Occupation

Date of Birth

Cell Phone

Email Address

Mailing Address (with City, State, Zip)

Medical Background

Please check if you have had or currently do have any of the following:

Allergies (Please specify type)

Other Medical Conditions

Pain, Injury, and Discomfort

Please check any affected areas:

Previous surgeries or invasive procedures (Please list type and year)

Goals & History

Name 3 results you want to accomplish (In order of priority)

What has gotten in the way of success in the past?

What do you want to learn more about?

Name specific areas you would like support

Lifestyle Patterns

Please note what type and frequency for the following:

Sugar

Caffeine

Soda

Diet or Sweetened Drinks

Alcohol

Nicotine

Artificial Sweeteners

Prescription/Rec. Drugs

Other Lifestyle Factors:

Conflict/Confrontation

Stress (Work, Family, Other)

Sleep (Length and Quality)

Exercise (Type and Frequency)

Workstyle

Any other information that would help us support you in being successful?

I acknowledge that the above information is complete and accurate to the best of my knowledge. I understand this is used to build a restorative protocol for my body.