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Jasthetics Clinic — New Client Wellness Intake Form
Section 1: About You
What's your full name?
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What's your date of birth?
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What's your email address?
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What's the best phone number to reach you on?
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How did you hear about Jasthetics?
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Section 2: Your Main Health Concerns
In your own words, what's the main reason you're booking this consultation today?
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Which of the following health areas are you looking to address? (Tick all that apply)
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Which of the following health areas are you looking to address? (Tick all that apply)
Hair (thinning, shedding, slow growth)
Hormonal imbalance / menstrual issues
Fatigue / low energy
Gut / digestive issues
Weight / metabolism
Sleep problems
Mood / anxiety / brain fog
Nutrient deficiencies (iron, B12, Vit D)
General wellbeing / prevention
Skin (acne, breakouts, pigmentation)
Other
How long have you been experiencing these concerns?
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What have you already tried for these concerns? (Tick all that apply)
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What have you already tried for these concerns? (Tick all that apply)
GP / doctor visit
Prescription medication
Over-the-counter medication
Supplements / vitamins
Dietary changes
Private specialist / consultant
Blood tests / private testing
Nothing yet
What outcome are you hoping for from this consultation? What would feel like a win for you?
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Section 3: Skin & Hair Health
Do you have any skin concerns? (Tick all that apply)
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Do you have any skin concerns? (Tick all that apply)
Acne / breakouts
Post-inflammatory hyperpigmentation (PIH / dark marks)
Dryness / dehydration
Sensitivity / redness
Rosacea
Premature ageing / fine lines
Dullness / uneven texture
Eczema / psoriasis
No specific skin concerns
Tell me about your current skincare routine if you are interested in my advice for skin — what products are you using day and night? (Include cleanser, serums, moisturiser, SPF, actives like retinol or acids if relevant)
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Do you have any hair concerns? (Tick all that apply)
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Do you have any hair concerns? (Tick all that apply)
Excessive shedding / hair fall
Thinning / reduced volume
Slow growth
Scalp issues (dandruff, itching, oiliness)
Receding hairline
No hair concerns
Have you had any previous professional skin or hair treatments? (e.g. facials, chemical peels, microneedling, PRP, laser, hair growth treatments)
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Section 4: Gut & Digestive Health
How often do you typically open your bowels?
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Do you experience any of the following digestive symptoms? (Tick all that apply)
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Do you experience any of the following digestive symptoms? (Tick all that apply)
Bloating
Gas / wind
Acid reflux / heartburn
Nausea
Loose stools / diarrhoea
Constipation
Stomach cramps / pain
Undigested food in stools
No digestive symptoms
Do you have any known food intolerances or sensitivities? If yes, please list them
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Have you ever been diagnosed with or treated for any of the following? (Tick all that apply)
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Have you ever been diagnosed with or treated for any of the following? (Tick all that apply)
IBS (Irritable Bowel Syndrome)
IBD (Crohn’s / Ulcerative Colitis)
H. pylori infection
SIBO (Small intestinal bacterial overgrowth)
Coeliac disease / gluten sensitivity
Frequent antibiotic use (3+ courses)
None of the above
Section 5: Hormonal & Menstrual Health
How would you describe your menstrual cycle?
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How would you describe your menstrual cycle?
A
Regular (every 21–35 days)
B
Irregular
C
Very short cycles (less than 21 days)
D
Very long cycles (more than 35 days)
E
No periods (amenorrhoea)
F
On contraception (no natural cycle)
G
Perimenopausal / menopausal
H
Not applicable / male
Do you experience any PMS or cycle-related symptoms? (Tick all that apply)
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Do you experience any PMS or cycle-related symptoms? (Tick all that apply)
Mood changes / irritability
Bloating / water retention
Breast tenderness
Heavy periods
Painful periods
Spotting between periods
Skin breakouts before period
None / N/A
Have you ever been diagnosed with any of the following? (Tick all that apply)
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Have you ever been diagnosed with any of the following? (Tick all that apply)
PMOS (Polymetabolic Ovararian Syndrome)
Endometriosis
Hypothyroidism (underactive thyroid)
Hyperthyroidism (overactive thyroid)
Hashimoto’s thyroiditis
Fibroids
Perimenopause / menopause
None of the above
Are you currently using any form of contraception?
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Are you currently pregnant or breastfeeding?
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Are you currently pregnant or breastfeeding?
A
No
B
Yes, currently pregnant
C
Yes, currently breastfeeding
D
Recently given birth (within 12 months)
E
N/A
Section 6: Energy, Sleep & Stress
How would you rate your overall energy levels? (0 = exhausted all the time, 10 = consistently energised)
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How would you rate your overall energy levels? (0 = exhausted all the time, 10 = consistently energised)
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How does your energy typically feel throughout the day?
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How does your energy typically feel throughout the day?
A
Good in the morning, crashes in the afternoon
B
Slow to start in the morning, better later
C
Consistently low all day
D
Crashes after meals
E
Reasonable but not optimal
F
Generally good
How would you rate your stress levels on a typical day? (0 = no stress, 10 = extremely stressed)
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How would you rate your stress levels on a typical day? (0 = no stress, 10 = extremely stressed)
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How would you rate your sleep quality? (0 = terrible, 10 = sleep like a baby every night)
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How would you rate your sleep quality? (0 = terrible, 10 = sleep like a baby every night)
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On average, how many hours of sleep do you get per night?
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Do you experience any of the following? (Tick all that apply)
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Do you experience any of the following? (Tick all that apply)
Low mood / feeling flat
Anxiety / worry
Brain fog / poor concentration
Irritability
Waking in the night / broken sleep
Difficulty falling asleep
Feeling overwhelmed
None of the above
Section 7: Diet & Nutrition
How would you describe your dietary pattern?
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How would you describe your dietary pattern?
A
Omnivore (eat everything)
B
Vegetarian
C
Vegan
D
Pescatarian
E
Gluten-free
F
Dairy-free
G
Low carb / Keto
H
Other / it’s complicated!
How many meals do you typically eat per day?
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How many meals do you typically eat per day?
A
1–2 meals (skip breakfast or lunch regularly)
B
3 meals a day
C
3 meals plus snacks
D
Intermittent fasting / time-restricted eating
E
It varies day to day
How many glasses of water do you drink per day?
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Which of these do you eat regularly (at least 2–3 times per week)? (Tick all that apply)
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Which of these do you eat regularly (at least 2–3 times per week)? (Tick all that apply)
Red meat (beef, lamb, pork)
Leafy greens (spinach, kale, broccoli)
Eggs
Oily fish (salmon, mackerel, sardines)
Dairy products (milk, cheese, yoghurt)
Legumes / beans / lentils
Nuts and seeds
None of the above
Section 8: Medical History & Medications
Do you have any diagnosed medical conditions? Please list them below
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Are you currently taking any prescription medications? Please list them with doses if possible
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Do you have any known allergies or intolerances (medications, foods, or otherwise)?
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Is there any significant family history of the following? (Tick all that apply)
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Is there any significant family history of the following? (Tick all that apply)
Thyroid conditions
Type 2 diabetes
Heart disease / cardiovascular disease
Autoimmune conditions
Cancer
Mental health conditions
None / not aware of any
Have you had any blood tests or medical investigations recently? If yes, please share any key results or what was tested or upload a photo (e.g. ferritin, B12, Vit D, thyroid, hormones)
Upload test results here
Click to choose a file or drag here
Size limit: 10 MB
Section 9: Lifestyle & Wellbeing
How often do you exercise or do structured physical activity?
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Do you currently smoke or vape?
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Do you currently smoke or vape?
A
No, never smoked
B
Yes, I smoke cigarettes
C
Yes, I vape
D
Ex-smoker (stopped more than 1 year ago)
E
Occasional / social smoker
How much time do you typically spend outdoors / in natural sunlight each day?
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Section 10: Current Supplements
Are you currently taking any supplements or vitamins? Please list them below including the name, dose, brand (if you know it), and how long you've been taking them
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Have you noticed any reactions or side effects from any supplements you've tried in the past?
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Section 11: Your Goals & Expectations
What are your top 3 health goals? What would feeling your best actually look like for you?
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Are you working towards any specific event or timeline? (e.g. wedding, holiday, fertility plans, a health target by a certain date)
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Is there anything else you'd like me to know before your consultation? This is your space — nothing is too small or too big to mention!
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