R&R
Root & Remedy Home Co.
R&R

Your Founding Family
Intake Form

Thank you for being one of our very first Root & Remedy families. This intake helps Dr. Kleiner build your personalized Home Wellness Snapshot before your visit. Takes about 10–15 minutes.

43 questions
~10–15 minutes
Fully confidential
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About Your Family
What are the full names of the adults in your household?*
Please enter your name to continue.
About Your Family
What town do you live in?*
Please enter your town.
About Your Family
How many people live in your home, and what are their ages?*
Include all adults and children. e.g. "2 adults, kids ages 4, 7, and 10"
Please describe your household.
About Your Family
What type of home do you live in?
Single family home
Townhouse or condo
Apartment
Other
About Your Family
How old is your home approximately?
Less than 10 years old
10–30 years old
30–50 years old
50+ years old
Not sure
About Your Family
Have you had any known mold, water damage, or flooding in your home?
No
Yes — resolved
Yes — ongoing or unsure
About Your Family
What prompted you to apply for a Root & Remedy assessment?
Health History & Symptoms
Does anyone in your household experience any of the following regularly?
Select all that apply.
Headaches or migraines
Fatigue or low energy
Brain fog
Skin issues (eczema, rashes)
Respiratory issues
Gut issues (bloating, IBS)
Hormonal imbalance
Allergies or sensitivities
Sleep issues
Anxiety or mood changes
Recurrent illness
Thyroid issues
Autoimmune condition
Fertility challenges
None of the above
Health History & Symptoms
Which family member(s) have these symptoms, and how long?
Health History & Symptoms
Any known allergies, chemical sensitivities, or diagnosed conditions we should know about?
Health History & Symptoms
Is anyone in the household currently pregnant, breastfeeding, or trying to conceive?
No
Yes — currently pregnant
Yes — breastfeeding
Yes — trying to conceive
Prefer not to say
Cleaning Products · Scored
What do you primarily use to clean kitchen counters and surfaces?
Branch Basics, EWG-verified, or certified non-toxic cleaner
0 pts
Seventh Generation, Method, or similar "natural" brand
1 pt
Mrs. Meyer's, Honest Co., or similar (contains fragrance)
2 pts
Clorox, Lysol, or conventional multi-surface cleaner
3 pts
Disinfecting wipes (Clorox, Lysol)
4 pts
Cleaning Products · Scored
What do you use to clean your bathrooms?
Branch Basics or certified non-toxic cleaner throughout
0 pts
Mix of natural and conventional products
2 pts
Conventional cleaners (Scrubbing Bubbles, Comet, Tilex)
3 pts
Bleach-based or strong disinfectants regularly
4 pts
Cleaning Products · Scored
What do you use to wash dishes?
EWG-verified or certified non-toxic dish soap
0 pts
Method, Seventh Generation, or similar
1 pt
Dawn, Palmolive, or conventional dish soap
2 pts
Conventional dishwasher pods (Cascade, Finish)
3 pts
Both conventional dish soap and dishwasher pods
4 pts
Cleaning Products · Scored
How often do you use air fresheners, plug-ins, candles, or synthetic fragrances?
Never — fragrance free home
0 pts
Occasionally — only natural candles or essential oils
1 pt
Regularly — scented candles or wax melts
2 pts
Daily — plug-ins, sprays, or synthetic fragrance diffusers
4 pts
Cleaning Products · Scored
Do you check ingredient labels on cleaning products before purchasing?
Always — I research every product carefully
0 pts
Sometimes — I try but don't always know what to look for
2 pts
Rarely — I buy what's familiar or on sale
3 pts
Never — I haven't thought about it before
4 pts
Laundry · Scored
What laundry detergent do you currently use?
Branch Basics, Molly's Suds, or EWG-verified detergent
0 pts
Seventh Generation Free & Clear or fragrance-free
1 pt
Method, Seventh Generation scented, or similar
2 pts
Tide, Gain, All, or other conventional detergent
3 pts
Scented conventional (Downy, Tide with Febreze, etc.)
4 pts
Laundry · Scored
Do you use dryer sheets or fabric softener?
No — I use wool dryer balls or nothing
0 pts
Unscented dryer sheets occasionally
1 pt
Scented dryer sheets (Bounce, Downy, etc.)
3 pts
Liquid fabric softener regularly
4 pts
Laundry · Scored
Do you use laundry boosters, stain removers, or bleach?
No, or only non-toxic options (Branch Basics Oxygen Boost)
0 pts
OxiClean or similar occasionally
1 pt
Conventional stain removers (Shout, Zout) regularly
2 pts
Chlorine bleach regularly
3 pts
Laundry · Scored
How would you describe the scent of your laundry products overall?
Fragrance-free — we intentionally avoid scented products
0 pts
Lightly scented — we prefer mild natural scents
1 pt
Moderately scented — we like our laundry to smell fresh
2 pts
Heavily scented — we love a strong clean laundry smell
4 pts
Personal Care · Scored
How do you choose personal care products — shampoo, body wash, lotion?
I research ingredients using EWG Skin Deep or Think Dirty
0 pts
I look for "natural" labels but don't verify ingredients
2 pts
I buy based on brand familiarity or price
3 pts
I haven't thought about personal care ingredients before
4 pts
Personal Care · Scored
What deodorant or antiperspirant do the adults in your home use?
Aluminum-free, clean deodorant (Native, Schmidt's, etc.)
0 pts
"Natural" deodorant but haven't verified ingredients
1 pt
Conventional antiperspirant (Secret, Degree, Dove, etc.)
3 pts
Clinical strength antiperspirant
4 pts
Personal Care · Scored
What products do you use on your children's skin and hair?
Skip if no children at home — just hit Next.
EWG-verified or certified clean kids' products throughout
0 pts
Mix of natural and conventional kids' products
2 pts
Conventional kids' products (Johnson's, Aveeno Baby, etc.)
3 pts
Same conventional adult products on children
4 pts
No children at home
N/A
Personal Care · Scored
How would you describe the makeup and cosmetics routine in your home?
Minimal or no makeup; clean ingredients throughout
0 pts
Some clean beauty brands but also conventional products
1 pt
Mostly conventional makeup and skincare products
3 pts
Heavy conventional makeup routine daily
4 pts
Personal Care · Scored
What type of sunscreen does your family use?
Mineral-only sunscreen (zinc oxide, titanium dioxide)
0 pts
Mix of mineral and chemical sunscreen
2 pts
Conventional chemical sunscreen (Coppertone, Banana Boat)
3 pts
Conventional chemical sunscreen daily and/or on children
4 pts
Kitchen & Food Storage · Scored
What do you primarily use for food storage?
Glass containers and beeswax wraps throughout
0 pts
Mix of glass and BPA-free plastic
1 pt
Mostly plastic containers and plastic wrap
2 pts
Plastic including older containers, bags, and wrap regularly
3 pts
Kitchen & Food Storage · Scored
What type of cookware do you primarily cook with?
Cast iron, stainless steel, or ceramic throughout
0 pts
Mix of safe and non-stick cookware
1 pt
Non-stick (Teflon/PTFE) pans — in good condition
2 pts
Non-stick pans that are scratched or worn
3 pts
Kitchen & Food Storage · Scored
How would you describe your family's diet overall?
Primarily whole foods, organic where possible, minimal processed food
0 pts
Mostly whole foods with some processed food weekly
1 pt
Mix of whole and processed foods, limited organic
2 pts
Primarily conventional, packaged, and processed foods
3 pts
Kitchen & Food Storage · Scored
What do you drink most often at home?
Filtered water — reverse osmosis or high quality filter
0 pts
Filtered water with basic pitcher filter (Brita, etc.)
1 pt
Unfiltered tap water
2 pts
Mostly bottled water in plastic
3 pts
Kitchen & Food Storage · Scored
Do you heat food in plastic containers or use plastic in the microwave?
Never — always glass or ceramic in the microwave
0 pts
Occasionally — mostly aware but sometimes use plastic
1 pt
Regularly heat food in plastic containers
2 pts
Always use plastic containers and wrap in microwave
3 pts
Air & Water Quality · Scored
Do you have any air filtration in your home?
Yes — whole home HEPA filtration or high quality air purifiers
0 pts
Yes — one air purifier in bedroom or main living area
1 pt
Standard HVAC filter only, changed regularly
2 pts
No air filtration or HVAC filter rarely changed
4 pts
Air & Water Quality · Scored
How often do you open windows and ventilate your home?
Daily when weather allows — we prioritize fresh air
0 pts
A few times a week
1 pt
Rarely — we keep windows closed most of the time
2 pts
Almost never
3 pts
Air & Water Quality · Scored
Do you have a water filter for drinking water?
Yes — reverse osmosis or whole-home filtration system
0 pts
Yes — pitcher filter (Brita, ZeroWater, etc.)
1 pt
No — we drink tap water
2 pts
No — we primarily drink bottled water in plastic
3 pts
Kids' Products · Scored
What do your children use for lunch containers, water bottles, and snack storage?
Skip if no children — hit Next.
Stainless steel or glass throughout — no plastic
0 pts
Mix of stainless steel and BPA-free plastic
2 pts
Mostly plastic — BPA-free labeled
3 pts
Conventional plastic containers, bags, and bottles
5 pts
No children at home
N/A
Kids' Products · Scored
How aware are you of ingredients in your children's everyday products — toys, art supplies, clothing?
Skip if no children — hit Next.
Very aware — we research and choose non-toxic products intentionally
0 pts
Somewhat aware — we try but it feels overwhelming
2 pts
Not very aware — haven't thought much about kids' product ingredients
4 pts
Not at all aware — this is entirely new territory for us
5 pts
No children at home
N/A
Goals & Priorities
Which areas are you most eager to address?
Select up to 3.
Kitchen & Pantry
Cleaning Products
Laundry
Personal Care & Bathroom
Kids' Products & Bedrooms
Air Quality
Water Quality
Food & Pantry Ingredients
Goals & Priorities
What does success look like after this assessment? What would you love to walk away with?
Goals & Priorities
What feels most overwhelming about making your home healthier right now?
Goals & Priorities
What is your approximate monthly budget for making product swaps after the assessment?
Under $50/month — slow and steady is fine
$50–$100/month
$100–$200/month
$200+/month — I'm ready to make changes quickly
Not sure yet — I'd like guidance on where to prioritize
Goals & Priorities
Where do you typically shop for household and personal care products?
Select all that apply — helps Dr. Kleiner make recommendations that fit where you already shop.
Target
Amazon
Whole Foods
Trader Joe's
Costco or BJ's
Local health food store or co-op
Stop & Shop / ShopRite / Big Y
Thrive Market (online)
Direct from brand websites
Other
Almost Done
Is there anything specific you'd like Dr. Kleiner to focus on or be aware of before your visit?
Your Home Toxin Burden Score
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/ 100

Your home has real opportunity.

One Last Step
What email address should Dr. Kleiner use to reach you?*
Please enter a valid email address.

By submitting you agree that your responses will be shared with Dr. Janelle Kleiner at Root & Remedy Home Co. for the purpose of your home wellness assessment. All information is kept strictly confidential.

All done,
thank you.

Dr. Kleiner has received your intake and will review it personally before your visit. You'll hear from her within 24–48 hours with next steps including your visit confirmation and what to expect.

— Janelle 🌿
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