Body Ritual — Client Intake

01 — Personal Information

About You

Basic details for your client profile and communications.

First Name *

Last Name *

Date of Birth *

Biological Sex

Email Address *

Phone Number

Height

Current Weight (lbs)

Starting Weight (lbs)

Goal Weight (lbs)

How did you hear about us?

02 — Health Background

Medical Background

Your health background helps inform your curation. All information is strictly confidential. Please consult your physician before beginning any new supplement regimen.

Current Medications & Supplements

Known Allergies or Sensitivities

Diagnosed Medical Conditions — check all that apply

Diabetes / Pre-diabetes Thyroid disorder Active or history of cancer Autoimmune condition Cardiovascular disease Kidney / Liver disease Hypertension Hormonal imbalance (PCOS, etc.) Sleep apnea GI / Digestive disorders Mental health condition None of the above

Past Surgeries or Procedures

Family Medical History (notable)

Do you smoke or use tobacco?

No Yes Former

Alcohol use

Are you pregnant or breastfeeding?

No Yes N/A

03 — Goals & Lifestyle

Your Goals

Understanding your goals and lifestyle helps inform your supplement curation.

Primary goals — select all that apply

Fat Loss / Body Recomposition Muscle Growth & Recovery Longevity & Anti-Aging Cognitive Performance Energy & Vitality Libido & Sexual Wellness Skin Health & Collagen Immune Support Sleep Optimization Injury Recovery / Joint Support Gut Health Hormone Optimization

Weekly exercise frequency

Primary type of exercise

Average sleep per night

Current diet / nutrition approach

Describe your main goal in your own words

04 — Supplement Experience

Prior Use & Preferences

Help us understand your familiarity and any prior experience with supplements or related products.

Have you used supplements like these before?

No, this is new to me I've researched but never used Yes, I have prior experience

What have you previously used? Any notable experiences or reactions?

Comfort level with self-injection

Comfortable Willing to learn Prefer oral / topical Unsure

Have you used any of the following?

TRT / Testosterone HGH / Growth Hormone SARMs Nootropics GLP-1 products None

Monthly budget range

Helps us tailor your curation to your comfort range.

Anything else we should know

05 — Acknowledgement

Before You Submit

Please read and acknowledge the following.

The information provided in this form is accurate and complete to the best of my knowledge. I understand that Body Ritual is a wellness curation service and not a medical practice. Nothing provided by Body Ritual constitutes medical advice, diagnosis, or treatment. All products are supplements intended for informational purposes only and are not intended to diagnose, treat, cure, or prevent any disease or medical condition. I acknowledge that individual results vary and are not guaranteed. I understand that I am solely responsible for consulting my own qualified healthcare provider independently. I agree to notify Body Ritual of any relevant health changes when updating my profile.

I confirm that all information provided in this form is truthful and accurate. * I have read and understand the acknowledgement above and agree to proceed on that basis. *

Digital Signature *

Type your full legal name as your digital signature

Date

Your information is confidential and securely stored

Intake Complete

Thank you for submitting your intake.
We will review your information and be in touch shortly.

Body Ritual Intake

About You

Medical Background

Your Goals

Prior Use & Preferences

Before You Submit

Intake Complete