CLIENT INTAKE & CONSENT FORMComplete this form to begin your wellness journey with us. Name * First Name Last Name Preferred Name/Nickname Date of Birth MM DD YYYY Age Phone Number (###) ### #### Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country How did you hear about Sanadi Life? Preferred Communication Preferred Contact Method Email Text Phone Call Preferred Consultation Format Zoom Video Call Phone Call Health & Wellness History How would you currently rate your overall health? 1 2 3 4 5 6 7 8 9 10 Do you have any diagnosed medical conditions? No Yes (Please specify) Family Health History (Any significant conditions?) No Yes (Please specify) Medications & Supplements Allergies & Sensitivities (Please be specific) No known allergies or sensitivities Yes Hormonal Health Do you experience any of the following? (Check all that apply) Irregular cycles Severe PMS/PMDD Menopause symptoms Thyroid issues Adrenal fatigue/HPA dysfunction Fertility concerns Other If menstruating (Average cycle length) Last menstrual period Sleep Patterns Average hours of sleep per night Typical bedtime Wake time Sleep quality (Check all that apply) Sleep well and wake refreshed Trouble falling asleep Frequent night waking Don’t feel rested after sleep Use sleep aids Stress Levels: Current stress level 1 2 3 4 5 6 7 8 9 10 Primary sources of stress How do you currently manage stress? Digestive Health: Do you experience any of the following? (Check all that apply) Bloating Gas Constipation Diarrhea Acid reflux/heartburn Food sensitivities IBS or other digestive conditions Other Bowel movement frequency Current Blood Work Date of most recent labs Lifestyle & Wellness Practices Nutrition Current dietary approach Omnivore Paleo/Keto Vegan/Vegetarian Mediterranean Gluten-free Dairy-free Other Meals per day Snacks between meals Yes No Water intake (cups per day) Food aversions or restrictions Typical meals Breakfast Lunch Dinner Snacks Physical Activity Exercise frequency Rarely/Never 1–2× per week 3–4× per week 5+ times per week Preferred forms of movement Average session duration Any physical limitations or injuries? Skincare Routine Morning skincare products Evening skincare products Weekly treatments (masks, exfoliants, etc.) Professional treatments (facials, peels, etc.) Main skin concerns (Check all that apply) Acne/breakouts Fine lines/aging Hyperpigmentation Dryness Sensitivity/redness Uneven texture Others Lifestyle Habits Caffeine consumption (type & amount) Alcohol consumption (type & frequency) Tobacco/nicotine use (type & frequency) Recreational substance use (optional) Average screen time (hours per day) Time spent outdoors (hours per week) Goals & Expectations Top 3 Wellness Priorities (Rank 1–3) Aging concerns (skin, energy, vitality) Weight management Sleep optimization Digestive health Energy levels Hormonal balance Stress reduction Emotional wellbeing Hair health Skin health Other Wellness Goals Short-term (1–3 months) Long-term (6–12 months) Previous Approaches What have you previously tried What worked well What didn’t work Time Commitment 5–10 minutes daily 15–30 minutes daily 30+ minutes daily Other Budget for Supplements/Wellness Tools (Optional) Under $100/month $100–$250/month $250+/month Medical Disclaimer & Consent By signing below, I confirm the following: ・I have provided accurate and complete information to the best of my knowledge. ・I understand that all recommendations provided are for general wellness and educational purposes only and do not constitute medical advice, diagnosis, or treatment. ・I acknowledge that Sydney Sajadi and Sanadi Life LLC are not licensed medical professionals, and I should consult my physician before implementing any significant changes to my health, diet, supplements, skincare, or lifestyle. ・I accept full responsibility for my personal health decisions and release Sanadi Life LLC and Sydney Sajadi from any liability related to my participation in this consultation. ・I understand that individual results may vary, and no specific outcomes are guaranteed. ・I consent to be contacted by Sanadi Life LLC regarding my consultation and personalized wellness plan. Photo/Progress Documentation (Optional) I consent to the following uses of before/after photos (Check all that apply) For personal records only Anonymous educational use Testimonials with my written consent I do not consent to any photo documentation Thank you!
