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Daylume Wellness Intake
What is your email address?
*
What is your first name?
*
What is your exact age? (Please enter a number)
*
What is your biological sex?
*
What is your biological sex?
A
Female
B
Male
C
Non-binary
I confirm that I am 18 years of age or older
*
I confirm that I am 18 years of age or older
Yes, I confirm that I am 18 or older
Are you currently pregnant or postpartum?
*
Are you currently pregnant or postpartum?
A
No
B
Currently pregnant
C
Postpartum
D
Prefer not to say
What is your natural wake time?
*
What is your natural wake time?
A
Before 6am
B
6-7:30am
C
7:30-9am
D
After 9am
What is the current season where you live?
*
What is the current season where you live?
A
Spring
B
Summer
C
Fall
D
Winter
What city or region do you live in?
*
What are your main wellness goals? Select all that apply.
*
What are your main wellness goals? Select all that apply.
What is your current stress level on a scale of 1-10
*
What is your current stress level on a scale of 1-10
A
1-3
B
4-5
C
6-7
D
8-10
How do you describe your sleep quality?
*
How do you describe your sleep quality?
A
Excellent
B
Good
C
Struggle
D
Poor
Do you have injuries or physical limitations?
Do you have injuries or physical limitations?
A
None
B
Minor limitations with modifications
C
Significant limitations
If you have significant physical limitations, please describe them here.
Are you currently taking any prescription medications?
*
Are you currently taking any prescription medications?
A
No
B
Yes
C
Prefer not to say
How would you describe your current exercise habits?
*
How would you describe your current exercise habits?
A
Sedentary
B
Lite
C
Moderate
D
Athletic
How would you describe your eating habits?
*
How would you describe your eating habits?
A
Inconsistent
B
Average
C
Intentional
D
Optimized
How would you describe your inner life or spiritual orientation? Select all that apply.
*
How would you describe your inner life or spiritual orientation? Select all that apply.
Which of these best describes your current life context? Select all that apply.
*
Which of these best describes your current life context? Select all that apply.
What is your biggest obstacle to feeling your best right now? Be as honest as you'd like.
*
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