Intake Form

Primary Concerns

What are your main health, energy, or lifestyle concerns?
Stress / AnxietyFatigue / Low EnergySleep IssuesDigestive Issues / BloatingInflammation / PainWeight Gain / MetabolismHormonal ImbalanceBrain Fog / MemoryCirculation / Heart HealthSkin IssuesLearning / Focus Challenges

Other concerns:

When did these concerns begin?

How severe are your symptoms?
MildModerateSevere

Current Health Status

Do you have any diagnosed medical conditions?

Are you currently taking medication?
NoYes

If yes, list medications:

Are you currently taking supplements?
NoYes

If yes, list supplements:

Do you experience frequent inflammation?
YesNo

Digestive health:
GoodBloatingConstipationLoose stool

Sleep quality:
GoodInterruptedDifficulty falling asleep

Lifestyle & Habits

Energy level during the day:
HighModerateLow

Water intake:
LowModerateHigh

Diet type:
MixedVegetarianVeganHigh ProteinOther

Alcohol consumption:
NoneOccasionalWeekly

Exercise frequency:
None1–2x/week3–5x/weekDaily

Stress level:
LowModerateHigh

Mental & Emotional Wellness

Do you experience:
AnxietyOverthinkingEmotional stressTrauma

Focus & concentration:
StrongModeratePoor

Mood patterns:
StableMood swingsLow mood

Do you feel mentally overwhelmed?
YesNo

EWS Bio-Scan (Energy Wellness System)

This scan analyzes energy patterns, stress load, and organ system balance.

Are you open to identifying root causes of imbalance?
YesNo

Have you done any bio-energy scans before?
NoYes

Goals for this scan:
Identify imbalancesPrevent future issuesOptimize performanceImprove overall wellness

9D NLS (Non-Linear System Analysis)

This scan provides deep insight into organs, tissues, and functional patterns.

Are you experiencing chronic or recurring issues?
YesNo

Areas of concern: (Check all that apply)
BrainHeartLiverKidneysDigestive systemHormonesImmune system

Do you want a detailed report with recommendations?
YesNo

HumePod Body Analysis

This scan measures body composition, muscle mass, fat %, hydration, and metabolic health.

Fitness goal:
Weight LossMuscle GainMaintenanceHealth Optimization

Do you track your weight or body metrics?
YesNo

Areas you want to improve:
Belly fatMuscle toneStrengthEndurance

Learning & Performance (Optional Add-On)

Do you or your child struggle with:
ReadingMathFocusMemory

Are you interested in a learning diagnostic + skill-building plan?
YesNo

Goals & Expectations

What are your top 3 goals?

What results are you hoping to achieve?

Consent & Disclaimer

I understand that the services provided by Renée Dhani™ Wellness & Learning (EWS, 9D NLS, HumePod) are non-medical wellness tools designed to support awareness, lifestyle improvements, and preventative health.

• These services do not replace professional medical advice or treatment.

• All recommendations are educational and not prescriptive.

• I acknowledge this is not a medical diagnosis.

• I consent to bioscans and analysis.

• Consult a doctor before changing your regimen.

If client is 18 or older:

Client Signature *

Date

If client is under 18:

Parent/Guardian Name

Guardian Signature

Relationship to Client

Date