diet, lifestyle & wellness form

Patient Details

First Name

Last Name

Samādhi Wellness Appointment Date

YYYY

Weekly Diet

Please provide the details of your typical eating patterns for the week, including meals, snacks, drinks as well as what time of day they are consumed.

Weekly Activity

Please provide the details of your typical activity patterns including work and hobbies, commitments and how you choose to relax

Sleep Assessment

Please provide the details of a typical night's sleep for you . Please include times and details, including activities before bed, screen time, lighting and electronics in the room, co-sleep companions (including pets!), waking during the night due to stress/anxiety/pain/discomfort/urination/hunger/nausea etc.

Wellness Assessment

Please provide details about a typical week for you – how you are feeling at certain times of the day, what you did to make yourself feel better, how you found a little joy (or not) and any mental health activities such as relaxation, mindfulness, meditation, yoga or breathing exercises. Include any affirmations you are using too!