Intake Form

MM slash DD slash YYYY

This information is very important to your health. Please take time to fill out this form completely. Please send any recent lab work or other test results that may be relevant, and bring all supplement bottles that you are regularly taking to your initial appointment. This helps us provide you with the best possible recommendations. Thank you!

Name(Required)
MM slash DD slash YYYY
Address(Required)
I currently do not have Health Insurance

Medical History

Have you had any major medical problems such as (check all that apply):
Current Symptoms

For Men Only

Do you have any of the following symptoms?

Routine Health Screening

Have you had a colonoscopy?

Social History

Marital Status
Are you or have you ever been a smoker?
Recreational drug use?
Have you ever been physically or sexually abused?
During the past 12 months, how often have you felt excessive stress in your life?

Exercise/Dietary

How many times per week do you exercise?
is exercise a struggle for you?
How would you describe your current eating habits?
Do you frequently skip meals?
How many times a week do you eat fast foods?
Do you follow any special diet?
Do you have any food cravings?
Are you currently at your target weight?

Please list the foods and drinks your typical meals/snacks would consist of

Family History

Adopted
Has any member of your family (including parents, grandparents and siblings) ever had the following?