Section 01

About You

The basics, so I know who I'm meeting.

First Name *

Last Name

Email Address *

Phone Number

Age

Location

Section 02

Your Health History

The fuller picture: what's brought you here, what's been tried, and what's still unexplained.

In your own words, what's been going on? *

Not the clinical version, the real one. How long, how it affects your daily life, what it's costing you.

Do you have any current or past diagnoses?

Include physical, hormonal, and mental health, formal or suspected.

Describe your physical health issues in your own words

Beyond a diagnosis: how does your body actually feel day to day?

Medications you're currently taking

Supplements you're currently taking

Have you had testing done, and what did it show? *

Yes, everything came back normal despite how I feel

Yes, some things were borderline or flagged

Yes, something was found but treatment hasn't made much difference

No recent testing

What have you already tried?

Practitioners, protocols, diets, supplements, programs. What helped, what didn't, what you've given up on.

Have you seen any of the following practitioners in the last 12 months?

Select all that apply.

What would you most like to change or improve about your health?

Section 03

Your Baseline

A few honest numbers. This is where we'll measure change from, not to judge, just to know where you're starting.

How would you rate your mental health right now? *

1 = very poor · 10 = excellent

1 · Very poor10 · Excellent

How would you rate your current stress levels?

1 = no stress · 10 = constant stress

1 · No stress10 · Constant stress

How would you rate your average daily energy? *

1 = completely depleted · 10 = vibrant and sustained

1 · Depleted10 · Vibrant

How much sleep do you get, on average, per night?

Do you wake feeling tired, even after a full night's sleep?

How would you rate the quality of your sleep? *

1 = poor sleep · 10 = fantastic sleep

1 · Poor10 · Fantastic

What's part of your night-time routine?

Select all that apply.

Section 04

Biology: Body & Daily Habits

Your body's daily inputs. Diet, movement, sleep, and hormones: the biological layer of the picture.

Diet & Movement

How would you describe your current diet? *

Mostly whole foods, though I still feel terrible

Mixed, I try but it varies day to day

Highly restricted, I've eliminated a lot trying to feel better

I use food to manage emotions or stress

I don't think about it much, but I feel depleted

Any dietary restrictions, intolerances, or specific choices?

How much intentional movement do you currently get? *

Very little, mostly sedentary

Occasional, once or twice a week

Regular, 3 to 4 times a week

Daily, a consistent part of my life

Possibly too much, I find it hard to rest

What type of exercise do you do, if any?

Food & Water

How often do you eat out or order in?

How many caffeinated drinks do you have per day?

What do you cook your food in?

Select all that apply.

Cast iron

Stainless steel

Non-stick / Teflon

Air fryer

What oils or fats do you cook with?

Select all that apply.

What type of water do you drink?

Tap water

Filtered water

Spring water

How much water do you drink per day?

1L (four glasses)

2L

3L or more

Where do you buy most of your fruit and vegetables?

Select all that apply.

Coles/Woolworths

Farmers markets

Organic store

Homegrown

Elimination & Substances

How often do you open your bowels?

Describe your bowel motions

Do you drink alcohol?

If yes, how often?

Do you use any tobacco or nicotine products?

Select all that apply.

Hormones & Cycle

Which best describes you?

No, I am post menopausal

Yes, I menstruate

No, I have yet to have my first bleed

Yes, but infrequently

No, I do not get my period

Do any of the following apply to you?

Select all that apply.

Hormonal birth control (e.g. the pill)

Cycle tracking (app or moon cycles)

IUD

Contraceptive implant

Hormonal injection

None

Section 05

Environment & Exposures

What surrounds you shapes you. Everyday exposures most people never think to name.

Are you aware of any environmental exposures that may be affecting your health?

Select all that apply.

High plastic use / exposure

Conventional cleaning products

Conventional beauty products

Unfiltered tap water

Possible mould exposure

Not sure / haven't considered this

Do you do any of the following?

Select all that apply.

Store hot food in plastic containers

Reheat food in plastic containers

Use a plastic chopping board

None of these

How often do you wear lycra, nylon, or polyester clothing?

This includes underwear and activewear.

Always

Sometimes

Never

What beauty and skincare products do you use daily?

Include brands where you can: deodorant, makeup, skincare, haircare.

Describe your home environment

e.g. do you live with housemates, family, alone, near industry or traffic?

Section 06

The Deeper Layer

The questions most practitioners don't ask. Share only what feels relevant and true.

Have you ever explored subconscious or mindset work before? *

No, this would be new territory for me

Yes, therapy or counselling

Yes, mindset work or coaching

Yes, somatic or body-based therapy

Yes, I've done PSYCH-K® before

Are there emotional experiences or patterns you believe may be connected to how you feel physically?

Share only what feels relevant and comfortable. This isn't about having the right answer. It's about the fuller picture.

Relationships & Connection

Do you have a strong, supportive network around you?

Are you currently in a relationship?

Is there anything about intimacy, connection, or your relationship with your body that feels relevant to share?

Entirely optional. Only share what feels useful for our work together.

Would you describe yourself as a person of faith or spiritual practice?

Looking Ahead

What does feeling truly well look like for you? *

Be specific. The life, not just the body.

Is there anything else you'd like me to know before we begin?

Root Cause Questionnaire

About You

Your Health History

Your Baseline

Biology: Body & Daily Habits

Environment & Exposures

The Deeper Layer

I can already see where we'll begin.

AMRTA WELLNESS