Dr. Holistica
Holistic Detox Journey
The Intake Assessment
Intentions & Identity
Name
Date of Birth
Marital Status
Occupation
Primary Intention: What is the #1 goal for your evolution?
The Vision: How do you want to feel in your body at the end of this journey?
The Motivation: On a scale of 1-10, how ready are you to make significant lifestyle changes? What has been your biggest obstacle in the past?
Clinical Foundation
Height (cm / ft-in)
Weight (kg / lbs)
Medical History: Any diagnosed conditions, recent surgeries, or dental amalgams?
Current Support: List all medications and supplements.
Recreational or Ritual Substances: Please share any substances you consume (alcohol, nicotine, or others) and their frequency.
Lab Work: Have you had blood work done in the last 6 months? If yes, please attach and send the results for clinical review.
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Ingen fil vald
Vitality Scale: Rate your daily energy from 1-10.
Safety Check: Are you currently pregnant, breastfeeding, or have any history of eating disorders?
Nutritional Alchemy
Current Fuel: (Standard diet, Vegan, Plant-based, or other patterns)
Fruit Intake: How much and what types of fruit do you currently eat?
Morning Rituals: What is the first thing you consume or do upon waking?
Caffeine Consumption: Daily intake of coffee, black tea, matcha, or chocolate?
Gut Health & Elimination: Note any bloating or gas. How many bowel movements do you have per day?
Hydration: Average daily water intake.
Movement & Vitality
Exercise Routine: Current frequency and types of physical activity.
Movement Joy: What activities make you feel most connected to your body?
Sedentary Load: How many hours a day do you spend sitting?
Sun Exposure: Average daily time spent outdoors in direct sunlight?
Skin Protection: Do you use sunscreen? If so, which brand/type?
Environmental Toxic Load
Air Quality: Usage of scented candles, plug-ins, or incense?
Laundry Rituals: Usage of fabric softeners or conventional detergents?
Personal Fragrance: Daily usage of perfume, cologne, or body sprays?
Body Care: Brand/type of deodorant and skincare currently used.
Digital Load: Average daily screen time and usage of "Blue Light" filters?
Inner Environment
Stress Architecture: Rate your average stress from 1-10.
Sleep Architecture: Do you wake up feeling refreshed or depleted?
The Mind: Current meditation, journaling, or breathwork habits?
Mental Landscape: How would you describe your current mental health and emotional well-being?
Final Commitment
Open Space: Is there anything else I should know about your lifestyle or support system before we begin?
The Leap: Are you ready to commit to this journey?
Yes
No
Submit Assessment
In health & clarity,
Marta Turpin, MD
Dr. Holistica