• Intake Form

    Fill out this mandatory Pre-Screen Assessment Questionnaire. **Filling out this form does not constitute medical advice and does not establish any kind of patient-physician relationship. A patient-physician relationship is only formed after you have formally been onboarded as a patient by the treating physician.
  • Format: (000) 000-0000.
  • Has your doctor ever said your blood pressure was too high or too low?*
  • Do you have a history of thyroid cancer or MEN Multiple Endocrine Neoplasm or any type of cancer or a family history of cancer?*
  • Do you have any known cardiovascular problems (abnormal ECG, previous heart attack, etc)?*
  • Has your doctor ever told you that your cholesterol was too high?*
  • Have you (or a family member) ever been told that you have diabetes?*
  • Are you taking any prescribed medications or dietary supplementation?*
  • Do you ever have problems sleeping?
  • Are you pregnant or post-partum ( Less than 6 weeks)?*
  • Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?*
  • Have you ever been diagnosed with any of the following?*
  • Do you have any other medical condition, injury or anything else we should be aware of that you have not mentioned?*
  • When was your last physical with labs?*
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  • If accepted into our program, will you take the prescribed medications and follow all recommended protocols and advice given to ensure your desired results?*
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