First Name
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Last Name
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Phone
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Email
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Date of birth
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Preferred Name
Sex Assigned at Birth
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Male
Female
Address
Street Address
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State
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City
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Postal Code
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Best Way to Reach You
Call
Text
Email
Marital Status
Occupation
How Did You Hear About Us
Referred By
Emergency Contact Name
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Emergency Contact Phone
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Emergency Contact Relationship
What Brings You In Today
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What are your goals? (check all that apply)
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Lose body fat
Build or keep muscle
More energy
Avoid dementia
Reduce heart attack risk
Clearer skin
Better sleep
Reduce stress
Improve blood sugar
Hormone balance
Healthy aging
Other
Improve sex drive
Improve sexual performance
Mental clarity and focus
Better mood
Recovery or injury healing
Athletic performance
One Thing to Fix in 90 Days
When Did You Last Feel Your Best
Services Interested In
Hormone therapy
Peptide therapy
GLP-1 / metabolic program
Functional medicine
Lab testing
Not sure yet
Rate each 1-10
Baseline Energy
Baseline Sex Drive
Baseline Sexual Performance
Baseline Mental Clarity
Baseline Memory
Baseline Mood
Baseline Motivation
Baseline Sleep Quality
Baseline Stress Level
Baseline Exercise Recovery
Body Composition Satisfaction
Hours of Sleep per Night
Wake Up Rested
Yes
Sometimes
No
Symptoms
Afternoon energy crash
Brain fog
Trouble falling asleep
Waking during the night
Anxiety
Irritability
Low mood
Weight gain around the midsection
Hard time losing weight
Loss of muscle or strength
Joint pain or stiffness
Hot flashes or night sweats
Irregular or heavy cycles
Erectile difficulties
Vaginal dryness
Hair thinning
Cold hands or feet
Sugar or carb cravings
Bloating or digestive issues
Low exercise tolerance
Current Medical Conditions
Past Surgeries or Hospital Stays
Current Medications and Doses
Current Supplements
Medication Allergies
Hormone Therapy Use
Never
In the past
Currently
GLP-1 Use
Never
In the past
Currently
Hormone or GLP-1 Details
Menstrual Status
Family History
Heart disease
Diabetes
High blood pressure
Thyroid disease
Cancer
Stroke
Dementia or Alzheimer's
Autoimmune disease
None known
Blood Work in Last 12 Months
Yes
No
Not sure
Height
Intake Weight (lbs)
Goal Weight (lbs)
Exercise Frequency
Type of Exercise
Strength training
Cardio
Sports
Walking
Yoga or mobility
None
Typical Day of Eating
Alcohol
Tobacco or Nicotine
Cannabis / Marijuana use
Caffeine per Day
Anything Else to Know
Insurance Card - Front
Insurance Card - Back
Driver's License - Front
Take a photo of the front of your driver's license with your phone
Driver's License - Back
Take a photo of the back of your driver's license with your phone
Insurance Company
Insurance Member ID
Insurance Group Number
Policyholder Name
Policyholder Relationship to Patient
Policyholder Date of Birth
Insurance Lab Cost Acknowledgment
I understand that using my insurance could make the blood labs more expensive than the set price. However, please still use my insurance for my labs.
Intake Acknowledgment
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I confirm the information I provided is accurate and complete to the best of my knowledge.
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