Vita Protocol Intake Form

Please complete the confidential health history form as thoroughly as possible, filling out all applicable sections based on your personal health history. The more detail you provide, the better we can understand your needs and support you effectively. If you have any questions or need assistance while completing the form, please don’t hesitate to ask—we’re here to help.

This is a judgment-free space—please share openly and honestly on this assessment. Cravings, food challenges, and eating habits can sometimes point to underlying imbalances in the body, many of which can be supported and corrected.

This form can not be saved with progress. Please allow yourself 30 - 45 minutes to complete this assessment.

Personal Information

First Name *

Last Name *

Email *

Phone Number *

Address *

Age *

Date of Birth *

Current Weight *

Height *

If minor name(s) of Parents/Guardians

In case of emergency notify (name) *

Phone *

Family Doctor

May we contact them?

Phone

Person Responsible for Payment *

Address *

Phone *

What are your major health concerns and intentions for contacting us?

Please list any current health conditions diagnosed by a medical doctor.

Have you had any bloodwork or exams within the last 2 months?

Please list all herbs, vitamins, and dietary supplements you are currently taking. Include dosage and frequency.

List all medications you are currently taking indicating whether they are over the counter or prescription. Include dosage and frequency.

List all medications, herbs, foods, environmental factors, to which you have a known allergy.

Please list any cravings you may have and time of day these occur - ex sugar or sweet foods after main meals, salt, breads, cookies mid-afternoon.

Please select if you currently or have utilized any of the following:

Aluminum pots, cookware, foil, deodorants and toothpaste containing aluminum.
Have or had mercury fillings in your teeth.
Have or do use a lot of soy foods or soy-based milks.
Have or had older carpets, wall to wall carpets.
Used pesticides, weed killers or harsh chemicals.
Prepare food in a microwave oven.
Wear synthetic materials.
Experience sensitivity to perfumes or other chemical odors.

Dietary Information

Describe below your typical meals. Please be as specific as possible. For example, instead of "oil" note the type of oil used. Instead of "bread" list the type of bread. Instead of "vegetables" list the type of vegetable, how prepared, canned, frozen or fresh. Please include all beverages, type and quantity.

Breakfast:

Morning Snack(s):

Lunch:

Afternoon Snack(s):

Dinner:

Amount of water consumed daily (number of glasses per day):

Any reccuring food cravings, such as salt, starch, sugar, chocolate, etc. Please list as many as applicable including time of day or month:

Family History

Please describe any relevant or major health related issues to the individuals below (cancer, mental illness, diabetes, heart disease, etc.)

Mother

Father

Sister(s):

Brother(s):

Maternal Grandparents:

Paternal Grandparents:

Medical History

List all major health problems including any operations. Note problem and year.

I, the undersigned, understands and acknowledges the following:

I acknowledge that Indigo Blessings operates as a Private Membership Association (PMA). By signing this agreement and engaging in services, I agree to enter into a private contract, removing my participation from the public domain into the private. I understand that as a member, I am choosing to access holistic, natural and alternative wellness services that may not be recognized, regulated, or approved by governmental agencies, including the FDA. This membership protects both practitioner and member, allowing natural and holistic care to be shared without the restrictions or stigma often associated with government oversight. By choosing to participate, I agree to abide by the Terms and Conditions of the Indigo Blessings PMA.

I understand that all services and evaluations offered by Indigo Blessings are holistic, natural, and spiritual in nature. Suggestions, remedies, and recommendations may include natural alternatives to pharmaceuticals, lifestyle guidance, energetic balancing, intuitive insights, or spiritual practices. These offerings are intended to support the body, mind, spirit, and environment in restoring balance and harmony. I further acknowledge that natural approaches often work gradually, and I accept that healing and improvement may require time, consistency, and personal commitment.

I recognize that all recommendations provided by Indigo Blessings are suggestions only, and I am solely responsible for deciding which to implement. I agree to use my own discernment and judgment when applying any advice, remedy, or practice, and I acknowledge that I am fully responsible for my health choices, lifestyle, and overall well-being. I also understand that results may vary from person to person, and that no specific outcomes, cures, or guarantees are promised or implied by Indigo Blessings or its practitioners.

I voluntarily choose to participate in the services offered by Indigo Blessings and release Indigo Blessings, its practitioners, members, and affiliates from all liability, claims, or damages that may arise from my participation in any of its services, programs, evaluations, or recommendations.

I further understand that all personal information, health details, and results shared with Indigo Blessings will remain strictly confidential. Records will be stored securely and will not be disclosed without my written consent. I acknowledge that my privacy and trust are valued and protected within this association.

By signing below, I confirm that I have read, understood, and agreed to this Private Membership Agreement & Disclosures. I consent to participate in the Indigo Blessings PMA and to engage in its services, programs, evaluations, and offerings under these conditions.

Welcome to Indigo Blessings!

We've received your client intake form and we're so excited to walk this journey with you. As a member you are entitled to a 20% discount on all services and store items. By utilizing the code "PMAMember" at checkout - applies to both in-person and online orders.

Welcome to the Indigo Blessings family - we're grateful to have you here.

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