Corporate Wellness Program: Client Intake Form

Your Wellness Goals

Constipation (less than 3 bowel movements a week)

Diagnosed with Pre-diabetes, Type 1 or Type 2 Diabetes

Diagnosed with Hypothyroidism or Hyperthyroidism

Frequent or excessive thirst and urination

Unexplained weight gain or difficulty losing weight

Difficulty losing weight despite diet and exercise

Gradual but consistent weight gain over time

Strong cravings for sugar, salt, or processed foods

Tendency to engage in emotional or stress eating

Body Mass Index (BMI) is in the overweight or obese category

Irregular, heavy, or painful menstrual cycles (if applicable)

Symptoms of PCOS (Polycystic Ovary Syndrome)

Severe PMS (Premenstrual Syndrome) symptoms

Mood swings, irritability, or feeling overwhelmed