Wellness Quickscan Screening Form

1
Name (Last)* This field is required.
2
Name (First)* This field is required.
3
Name (Middle)Optional
4
Date of Birth* This field is required.
Date
Month
Day
Year
5
Gender* This field is required.
Please Select
Please Select
Male
Female
6
What is your height?* This field is required.
Please Select
Please Select
4' 10" or under
4' 11"
5'
5' 1"
5' 2"
5' 3"
5' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5' 10"
5' 11"
6'
6' 1"
6' 2" or over
7
What is your weight?* This field is required.
Pounds
8
Email* This field is required.
example@example.com
9
Street Address* This field is required.
10
City* This field is required.
11
State* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
12
Zip* This field is required.
13
Phone Number* This field is required.
14
Primary Care Provider Name
15
Provider Phone Number
16
BRIEFLY DESCRIBE ANY CURRENT HEALTH CONCERNS OR WELLNESS GOALS YOU HAVE* This field is required.
17
WHAT HAVE BEEN YOUR BIGGEST STRUGGLES & CHALLENGES IN RELATION TO THESE GOALS?* This field is required.
18
ON A SCALE OF 1-10, HOW IMPORTANT IS HAVING PROFESSIONAL GUIDANCE AND SUPPORT IN YOUR JOURNEY TOWARDS OPTIMAL HEALTH?* This field is required.
1 (NOT IMPORTANT AT ALL)
2
3
4
5
6
7
8
9
10 (EXTREMELY IMPORTANT)
19
WHICH OF THE FOLLOWING WAYS WOULD YOU CONSIDER TO ENHANCE YOUR WELLBEING?* This field is required.CHOOSE ALL THAT APPLY
DIET ENHANCEMENTS
LIFESTYLE ENHANCEMENTS
SUPPLEMENTS
CUSTOM LABS
I'M NOT SURE
20
WOULD YOU PREFER TO HAVE YOUR PHARMACY QUICKSCAN SCREENING IN PERSON AT OUR FACILITY OR VIRTUALLY OVER THE PHONE?* This field is required.
IN PERSON AT HAZLET PHARMACY
VIRTUALLY (OVER THE PHONE)
Should be Empty: