Date Today
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DD
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Name
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First Name
Last Name
Email
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Phone
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
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MM
DD
YYYY
Name
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First Name
Last Name
Email
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Phone
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What is the activity level at your job?
Low (seated only)
Moderate (light activity such as walking)
High (heavy labour, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights?
How often do you travel long distance? (Journeys over 4 hours. For knowledge of sleep patterns and circadian rhythm)
Rarely
A few times a year
Monthly
Weekly
Do you currently go to the gym or take part in any physical activities?
No additional physical exercise
1-3 times a week
4-5 times a week
Everyday
Feel free to state activities and days here:
Physical
For example; tone the body, increase strength or weight loss.
Mental
For example; to be more focused or cope better with stress.
Spiritual
For example; to better understand my hunches, to connect to my intuition, release deep rooted stress (energetic blockages), to discover my purpose.
Personal
For example; to improve my relationships with other or to feel more comfortable with others.
Other
Any other miscellaneous goals you may have.
More information if applicable
Please let us know which programme, if any, you are interested in.
Stress Relief
Fulfil
Yogic Systems
Spiritual Journey
Sculpt and Lengthen
Which of the following options is of interest to you?
In Person sessions
Online sessions
Mixture of in person and online sessions
Time Zone
Please state your time zone or possible time zone if travelling to a regular location(s).
Location Preference
London
Buckinghamshire
Do you have a budget?
Do you have any preference on times and days to have your IDWellness sessions?
Please tick any health conditions that you currently or have previously experienced.
If you ticked any of the above, please use the space below for further details if applicable.
Are you currently taking any medications? Please give information in the space below.
During our services, to allow further relaxation, oils and other substances (such as Sage, Palo Santo and other plants (all legal) may secreted or into the surrounding air, via diffuser, burning them or applied on your skin. Some of these may contain traces of nuts and other allergy inducing substances. Please state if you have any allergies, intolerances, or skin conditions we need to be aware of or any objections to the use of oils and other substances used in this way.
Have you experienced pregnancy or given birth within in the last 6 months?
We may offer relevant modifications to keep you safe, provide specifically designed classes or look at releasing energy blockages. Please include information at your own absolute comfort and discretion. Please feel free to include information regarding previous pregnancies too.
Do you ever smoke or have you smoked in the past?
Yes
No
Smoker in the past
It is your responsibility to submit the correct information this form is and to let us know if any of the information submitted changes or no longer applies.
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I agree to the IDWellness Waiver of Liability for all IDWellness Services and Disclaimers of Warranties and Limitations on Liability for all IDWellness Services (Accessible at www.id-wellness.com/termsofservice)
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By using our services you agree to to our Terms and Conditions and Privacy Policy, including GDPR. (Terms of Service accessible at www.id-wellness/termsofservice and Privacy Policy, including GDPR available at www.id-wellness.com/privacypolicy
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