Confidential Personal Wellness Assessment

Confidential Personal Wellness Assessment

Start Your Journey to Total Wellness Today.
General Information
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Cell Phone*

Area CodePhone Number
Any Allergies*
Weight*
Height*
Gender
Will you be using your insurance to cover the medication?
if yes, provide insurance carrier name
if yes provide insurance member ID# Group # and RXbin#
insurance information
How will you be checking in?*
How did you hear about this program?
What are your top 3 goals for joining our program?
Health History
Are you under the care of a qualified healthcare professional? Please list.*
Are you in good health at the present time to the best of your knowledge? Yes No
Do You have a history of any of the following :*

Diabetes type 1Diabetes Type 2Severe renal/kidney impairment (with eGFR of 15 or below) or a history of renal disease.history of medullary thyroid cancer (MTC)Severe hepatic/liver impairment.History of pancreatitis, gallbladder disease, inflammatory bowel disease, diabetic gastroparesis.* Pregnancy, breastfeeding or trying to/planning to become pregnant.Congestive heart failurehistory of MEN 2 (Multiple Endocrine Neoplasia syndrome*NO History of any listed above
Do any immediate family members have a history of any of the following :

Diabetes type 1Diabetes Type 2Severe renal/kidney impairment (with eGFR of 15 or below) or a history of renal disease.family history of medullary thyroid cancer (MTC)Severe hepatic/liver impairment.History of pancreatitis, gallbladder disease, inflammatory bowel disease, diabetic gastroparesis.Hypersensitivity to Ozempic or to any of the excipients: disodium phosphate dihydrate, propylene glycol, phenol and water for injection. .Congestive heart failurefamily history of MEN 2 (Multiple Endocrine Neoplasia syndrome*NO family History of any listed above
What medications, supplements and over the counter items do you take regularly or are currently prescribed: ( list N/A if none)*
Any past surgeries and hospitalizations?*
Personal History
What is your line of work or study?
Do you exercise regularly? Please detail.
What kind of other movement or activities do you enjoy?
Do you have problems falling or staying asleep?
How many hours do you sleep?
Do you wake up refreshed?
How is your energy?
Does your energy level affect your daily activities?
How would you describe your mood, generally:
Does your mood affect your daily activities?
How would you describe your stress level?
What are your sources of stress?
How do you manage stress?
Do you have a personal support network?
Diet and lifestyle
Do you regularly drink alcoholic beverages?
If yes, how many per week?
Do you smoke tobacco?
Do you use recreational drugs?
How is your appetite?
How many meals per day do you eat?
What is a typical day, in terms of food intake? Please list all meals and snacks.
How much water do you normally drink? Please approximate in ounces.
Please list all types of beverages you regularly drink.
You many times per day do you eliminate? (poop)
Please list any food allergies, intolerance or foods you avoid and the reason.
What past struggles and difficulties have you experienced in terms of food and dieting?
What diet and exercise programs, protocols, plans or approaches have you tried in the past?
What types of diet and exercise approaches have worked for you in the past?
And what hasn't worked for you at all?
Let's get a current picture of your health

Health History*

	No, never	Yes, currently	Not currently, but within the last year	Not currently and longer than 1 year ago
Fatigue
Unexplained weight loss or gain
Change in appetite
Depressive symptoms
Anxiety
Mood swings
Nervousness
Addictive dependency
Disordered Eating Pattern/Tendency
Tension
Lack of mental focus
Thyroid problems
Diabetes
Blood sugar irregularities
Excessive thirst or hunger
Sugar cravings
Abnormal hair growth
Excessive perspiration
Feeling excessively hot or cold
Headache
Lightheadednes
Joint pain or stiffness
Muscle weakness or soreness
High blood pressure
Heart murmur/palpitations
Cold or pale extremities
Asthma
Short of breath
Heartburn
Abdominal discomfort after eating
Nausea
Abdominal bloating
Blelching/gas
Constipation
Diarrhea
Daily bowel movements

What are your top preferences for checking in?

	Top choice	Works ok	Doesn't work for me
Monday morning (9am-noon)
Monday afternoon (noon-6pm)
Tuesday morning (9am-noon)
Tuesday afternoon (noon-6pm)
Wednesday morning (9am-noon)
Wednesday afternoon (noon-6pm)
Saturday morning (10am-noon)
Saturday afternoon (noon-5pm)

The above are my standard office hours of operation. If none of the above work, please list days and times that would and I will try to work something out with you.
Our goal is to assist you in implementing lifestyle modifications you want to achieve. It is recommended that you seek advice from your medical care professional for your medical needs. Information given through this program is for wellness and educational purposes and is not intended to treat or cure any disease or medical condition. You will seek advice from your medical care professional for your existing medical needs*

I acknowledge
I understand that all information obtained through this program is for wellness and educational purposes only; that my information is private and will not be sold or shared in any way and that Fitz Six Wellness and associates are not responsible for my medical needs or concerns.*

I acknowledge
Just one last box to write here anything important that you'd like me to know before we begin.
Should be Empty:

Confidential Personal Wellness Assessment

General Information

Health History

Personal History

Diet and lifestyle

Let's get a current picture of your health