Vitopia Care Intake - On Demand

  • Ask On-Demand Consultation Intake

  • Member Information

    Basic information about you so we can create your Vitopia Care account.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Gender*

  • Disclaimer: If you close this form prior to completing it, you will not be able to continue from where you left off and will need to start over. You will not be deducted credits until after you complete this form.

  • Health History Profile

    This section is a reflection of your current and previous heath conditions and concerns. This information is not required at this time to complete your consultation. However, providing this information will help our Vitopia Care Guides make better recommendations for you.
  • Current Health Conditions (select all that apply)
  • Have you had any surgeries in the past 12 months?
  • Are there any other details about your health history that you have not already provided or that you would like a Vitopia Functional Care Guide to know?

  • Core Health Questions

    These questions will help a Vitopia Functional Care Guide get a picture of your overall health.
  • How many prescription medications are you currently taking?*
  • How would you rate your overall energy levels?*
  • How would you rate your movement and exercise?*
  • How would you rate your eating patterns and digestion?*
  • How would you rate your sleep?*
  • How would you rate your stress levels?*
  • How often do you get sick?*
  • Are you happy with your current weight and body composition?*
  • How do you feel you are aging?*
  • I value my health and I am committed to taking a positive approach to improving it.*

  • Health Story Questions

    A series of quick Yes/No questions to help gain insights into your lifestyle.
  • Do you drink more than 3 alcoholic beverages per week?*
  • Do you smoke (cigarettes, cigars, marijuana, vape)*
  • Do you have food allergies or intolerances?*
  • Do you have food cravings often (especially sugary or salty foods)?*
  • Are you under chronic stress, anxious, or do you have anxiety?*
  • Do you walk or exercise regularly?*
  • Are you more than 15 pounds overweight?*
  • Do you get tired after eating a large meal?*
  • Do you have problems with your memory, concentration, or focus?*
  • Do you take in more than the equivalent of 3 cups of coffee of caffeine in a day for energy?*
  • Do you have cold hands or feet?*
  • Do you eat a lot, but still cannot gain weight?*
  • Have you ever taken antibiotics for acne or have you taken antibiotics for a month or longer?*
  • Have you had or do you get skin rashes or eczema?*
  • Are you frequently suffering from constipation or diarrhea (or go back and forth between the two)?*
  • Do you get gassy or bloated easily, especially after eating a meal?*
  • Are you on proton pump inhibitors (PPIs) or other acid-supressing drugs (prescription or over the counter)?*
  • Do you get sick often?*
  • Do you often have itchy and/or watery eyes?*
  • Do you have swollen joints or joint pain?*
  • Do you usually have trouble falling asleep or staying asleep?*
  • Do you feel out of breath when walking up a flight of stairs?*
  • Do you experience swelling in your feet or ankles?*
  • Do you have high blood pressure?*
  • Do you find yourself irritable often?*

  • Health Talk Questions

    This section is designed to prepare you for your Health Talk, telling your health story, and targeting some specific idea around the care focus condition your Health Talk will be focused on.
  • Which Care Program are you seeking Functional Care Guidance for today?*
  • How long have you been experiencing your current health condition?*
  • Have you been diagnosed with your care focus condition by your primary healthcare practitioner?*
  • Do you have a diagnostic test you would like to have our Care Guides review?*
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  • Are you on your health improvement journey alone or do you have a social support network (e.g., family, friends, spouse, partner, children, even your pet(s))?*
  • How do you rate your social support network in supporting your health optimization journey?*

  • Drug-Induced Nutrient Depletion

    Care Program Questions
  • How long have you been taking this medication?
  • Do you regularly eat a well-balanced diet high in nutrients and supplement with a multiple vitamin/mineral formula?
  • Do you experience any gastrointestinal issues, have elevated liver function tests or fatty liver, or low kidney function that could impact drug metabolism and clearance?

  • Medication De-Prescribing

    Care Program Questions
  • Are you taking medications for a chronic (long-term) condition?
  • Are you experiencing side effects from your medication that impact your daily life?
  • Are you currently taking supplements because of your medications?

  • Healthy Body Composition

    Care Program Questions
  • Are you more than 5 pounds over your ideal body weight?
  • Is your current waist measurement over 31 inches if you are female or 37 inches if you are male?
  • Do you have high blood pressure or high cholesterol?

  • Gut Health

    Care Program Questions
  • Do you experience discomfort such as gas, bloating, constipation, diarrhea or heartburn more than twice a month?
  • Do you experience cravings for certain foods such as sugar and/or carbohydrates?
  • Do you have skin rashes or an autoimmune condition?

  • Heart & Vascular Health

    Care Program Questions
  • Do you have a family history of diabetes, high blood pressure or heart disease?
  • Do you have high cholesterol or triglycerides?
  • Do you regularly eat processed foods?

  • Healthy Metabolism

    Care Program Questions
  • Do you regularly crave sweets or carbohydrates shortly after eating a meal?
  • Do you regularly get tired or sleepy within 30 minutes to an hour after eating?
  • Do you have difficulty losing weight and keeping it off?

  • Immune Balance

    Care Program Questions
  • Do you get sick easily and or often (seem to catch everything that is going around)?
  • Do you never get sick (rarely if ever catch a cold or flu)?
  • Do you have an autoimmune disease?

  • Foundational Health - "Your Vitality"

    Care Program Questions
  • Have you completed our general health assessment to identify any areas of potential weakness or vulnerability?
  • Have you addressed any identified areas of concern?
  • Are you feeling great and ready to achieve optimal health?

  • Healthy Skin

    Care Program Questions
  • Have you been diagnosed with a skin condition such as eczema, psoriasis, rosacea, or acne?
  • Do you experience frequent rashes or breakouts?
  • Is your skin doing better on conventional treatment (prescriptions or topicals), but you desire to use a more holistic or natural method to maintain your skin health?

  • Healthy Aging

    Care Program Questions
  • Do you feel or look older than your chronological age?
  • Do you wish you had more energy or that you could be more active?
  • Do you experience brain fog, memory or mood problems?

  • Sleep Vitality

    Care Program Questions
  • Do you get at least 7-9 hours of sleep each night?
  • Do you experience microsleep (episodes of falling asleep for a few to several seconds without realizing it) during the day?
  • Do you feel the need to take naps during the day?
  • Do you experience reduced alertness or inability to concentrate?

  • Brain Health

    Care Program Questions
  • Have you had repeated blows to the head or a prior head injury with loss of consciousness, disorientation, confusion, or memory loss?
  • On average do you sleep less than six hours a night?
  • Do you have diabetes or high blood pressure?

  • Cancer Prevention

    Care Program Questions
  • Do you eat a diet high in vegetables and fruits and low in sugar and heavily processed foods?
  • Do you have diabetes or metabolic syndrome?
  • Do you have a family history of cancer?

  • Detoxification

    Care Program Questions
  • Have you had regular exposure to pesticides, chemicals, paints or cleaning materials in your home or workplace?
  • Do you regularly consume highly processed foods, alcohol, municipal water, artificial sweeteners, sodas or eat out on a frequent basis?
  • Do you have amalgam fillings or caps, root canals, or history of childhood cavities?

  • Stress Management

  • In the last month have you felt: (select all that apply)

  • Functional Care for Athletes

    Care Program Questions
  • Have you hit a plateau with your athletic plan?
  • Are you happy with your current body composition?
  • Are you looking to improve your routine, diet, or supplement regimen to optimize your athletic goals?

  • Healthy Thyroid

    Care Program Questions
  • Have you been diagnosed with Thyroid disease?
  • Do you feel extreme fatigue, weight changes, mood changes, constipation, feel cold easily, have increased hair loss, or dry skin.
  • Are you already doing better on conventional treatment (prescription medication) and want to optimize with the correct supplements, diet, and lifestyle modifications?

  • Long COVID

    Care Program Questions
  • Do you continue to experience exhaustion after COVID infection or vaccination that has not returned to pre-COVID levels?
  • Do you continue to experience mental decline (brain fog or other cognitive decline)?
  • Do you continue to experience any other symptoms which developed after COVID infection or vaccination which have not gone away?

  • Hormonal Balance (Male)

    Care Program Questions
  • Have you been diagnosed with “Low-T” (low testosterone), testosterone deficiency, andropause, or hypogonadism?
  • Would you like to treat your associated symptoms with lifestyle changes and supplementation?
  • Are you on conventional treatment (prescription medication) and feel you still have room for improvement, and/or desire to change over to a more holistic or natural method?

  • Hormonal Balance (Female)

    Care Program Questions
  • Have you been diagnosed with any of these conditions: PMS, PMDD, PCOS, PeriMenopause, Menopause?
  • Would you like to treat your associated symptoms with lifestyle changes and supplementation?
  • Are you on conventional treatment (prescription medication) and feel you still have room for improvement, and/or desire to change over to a more holistic or natural method?

  • Autoimmune Health

    Care Program Questions
  • Have you ever been diagnosed or told you have an autoimmune disease?
  • Do you tend to get sick whenever something is going around, or you are exposed to a virus or bacteria?
  • Are you on conventional treatment (prescription medication) and feel you still have room for improvement, and/or desire to change over to a more holistic or natural method?
  • Have you taken antibiotics in the past year?

  • Disclaimer: clicking submit will take you to the health story portion of the the intake process where you can record a short audio/video clip to give further information about your condition/symptoms.

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