Health History Intake Form Health History Intake Form "*" indicates required fields Step 1 of 12 8% CommentsThis field is for validation purposes and should be left unchanged.Personal InformationFull Name*Email* Phone number* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth* MM slash DD slash YYYY Gender* Male Female Other HeightFeet*Inches*Weight* How Did you hear about us?Emergency Contact Name & Phone Name*Phone*Consent to receive automated messages/reminders: Texts Calls E-mails Medical HistoryDo you have Current or past history of any of the following?(Check all that apply)* High blood pressure Diabetes (Type 1 or 2) High cholesterol Heart disease Stroke Sleep apnea Depression or anxiety Thyroid disorder Hashimoto's Thyroiditis Fibromyalgia Kidney or liver disease Seizure disorder Cancer Arthritis MTHFR gene mutation Hormone Imbalance Blood clot(DVT/PE) Varicose Veins Osteoporosis Eating disorder Drug/alcohol abuse (past or current) Heart palpitations Ventricular heart problems Arrhythmia Pacemaker IBS Constipation Diarrhea GERD Heartburn Pancreatitis Diverticulitis Bowel blockage Other Other*Type of Cancer* Food/Medication Allergies?* No Yes List of Allergies*Pregnant or breastfeeding? No Yes Current medications or supplements?* No Yes Current medications or supplements List* Past use of weight loss meds (e.g., phentermine, GLP-1, bupropion, other)?* No Yes Past use of weight loss meds List*Surgical History* No surgeries Yes Type / Date of Surgery* Family Medical History (Check applicable family members only)FatherMotherSiblings Lifestyle & GoalsDo you have any Weight Loss Goals?Do you have any Hormone Balance Goals?What Program or Service are you interested in?What are you struggling with?*(e.g. hunger, cravings, hormone balance, menopause, pre-menopause, mood swings, irritability, low Testosterone, difficulty losing weight, bloated belly, low energy, loss of muscle mass, lack of motivation to get started, meal planning, other? Meals/day?* 1 2 3 More Snacking?* Rarely Sometimes Often Exercise frequency?* Never 1–2x/week 3–5x/week Daily Sleep/night?* <5 hrs 5–6 hrs 7–8 hrs >8 hrs Alcohol use?* No Occasionally Frequently Drinks / Week*Tobacco use?* No Yes Packs/day* Recreational/illicit drug use (past or present)?* No Yes Type*Primary weight loss goals:* Lose weight/fat Improve energy Curb appetite/cravings Improve blood sugar Boost confidence/appearance Other Other Primary weight loss goals*Date of Form Completion* MM slash DD slash YYYY Consent* I confirm this information is accurate. I agree to this consent. My name represents my signature.*
