WellClinica
First Bloom Cohort — Intake Form

Tell me about
where you are right now.

This form helps me understand your health history, your symptoms, and your goals — so the protocol is as relevant to you as possible from day one. Take your time.

8–10 minutes to complete
Starts April 13, 2026
Completely confidential

Please complete this within 3 days of receiving your acceptance email. I review every form personally before the program begins — your answers directly shape how I guide you through the 8 weeks.

Personal Information

Name
Date of Birth

Medical History

Lifestyle & Nutrition

(e.g. weight loss, energy, digestion, hormonal balance)
You may choose to provide this information only if you feel comfortable sharing it. It is entirely optional and will be kept strictly confidential.
You may choose to provide this information only if you feel comfortable sharing it. It is entirely optional and will be kept strictly confidential.
You may choose to provide this information only if you feel comfortable sharing it. It is entirely optional and will be kept strictly confidential.
Please provide how many cups per day, and which coffee type, with or without creamer...
Please provide how many glass a week and which alcohol type ...
You may choose to provide this information only if you feel comfortable sharing it. It is entirely optional and will be kept strictly confidential.

Digestion & Elimination

Checkboxes

Stress, Mood & Mental Load

How would you rate your stress level?
Do you practice stress management (e.g. meditation, yoga, breathwork)?
Do you experience any of the following on a regular basis?

Sleep Patterns

Physical Activity & Movement

(e.g., walking, yoga, weights, HIIT)

Women’s Health (if applicable)

Are you currently:
Do you experience one of these symptoms?

Lifestyle Habits

(wake-up time, meals, work, downtime, bedtime)
What is your current occupation or daily role?

Food Relationship & Sugar Intake

(e.g. soda, sweetened coffee/tea, energy drinks, juice) ___ drinks per week

Grocery Shopping & Food Choices

Nutrition Planning

Consent
Jana, WellClinica

Thank you for taking the time to fill this in. Every answer matters — this is how I make sure HerBloom actually works for your body, not just the average client.

I'll review your form before April 13 and be in touch if I have any questions.

Jana
Board Certified Functional Nutritionist, CFNP — Founder, WellClinica
What happens next
1

Jana reviews your intake form before April 13

2

You'll receive portal access on April 8 — 5 days before the program begins

3

The First Bloom Cohort begins April 13, 2026 — your 8-week journey starts

Individual results may vary. This program is not intended to diagnose, treat, cure, or prevent any disease.

Questions? contact@wellclinica.ca · wellclinica.ca

© 2026 WellClinica. All rights reserved.