Initial Health Consultation Form

Initial Health Consultation Form

All orders placed are patient specific and are pending review by our nurse practitioner. Please allow up to 48 hours business hours for the nurse practitioner to reach out and set up an appointment with you after this form has been submitted. Expect up to two weeks for delivery of medication and/or supplements due to processing times with our compounding pharmacies.
I am aware that this form is HIPPA compliant and will only be used for the purpose of documentation in my Athena electronic health record (EHR) and for review during any telehealth or phone consultations. This information will not be shared with anyone outside of my healthcare team unless a release of information form has been completed and signed granting permission.*

Yes
I am aware that I must reside in NC to place any orders with the Wellness Shop currently.*

Yes
I am aware that Coastal Wellness NC has the right to refuse completion of my Wellness Shop order based upon their assessment of my responses if there are any medical concerns and/or contraindications.*

Yes
Please Note: We only have the Liraglutide GLP-1 compound available. We do not have the Tirzepatide or Semaglutide GLP-1 compounds available. We will monitor for any changes and update as appropriate. This is in accordance with the FDA decision made regarding national shortages. We do have several other options in addition to Liraglutide available for weight management that can be discussed.
Do you require a telehealth appointment for the weight management program?*

Yes, I am a new client, please contact me for an appointmentYes, it has been more than 30 days since I last ordered and I need an updated consultNo, I am re-ordering - STOP HERE & REQUEST CORRECT REORDERING FORMNo, I am ordering a different wellness shop supplement/product.
If you are interested in a consultation with our health coach, David, please select the appropriate response below. This is an INCLUDED service we offer to all clients and does not have any additional fee for you.*

Yes, please contact me for an appointmentN/A - I am not interested at this time
Required Demographic Information for your Athena Health Chart
Legal Name*

First NameLast Name
Preferred Nickname, if applicable:
Legal Sex*

MaleFemale
Preferred Pronouns:*

He/Him/HisShe/Her/HersThey/Them/Theirs
Date of Birth*

MonthDayYear
Shipping Address: Can NOT be a P.O. Box*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
Preferred Language: *
Race:*

CaucasianAfrican AmericanAmerican Indian or Alaskan NativeAsianNative Hawaiian or other Pacific Islander
Ethnicity:*

Hispanic or LatinoNot Hispanic or Latino
Marital Status:*

SingleMarriedPartnerSeparatedDivorcedWidowed
How did you hear about Coastal Wellness NC?*
Did anyone from CWNC help to answer your questions and/or help you place order?*
Please provide the staff member's name if applicable.
Medical Information To Be Reviewed and Verified During Your Visit
Have you ever used GLP-1 injections, or taken any other type of weight management medication previously? (Phentermine, Topamax, Metformin, Naltrexone, Wellbutrin, Contrave, etc.)*

YesNo
If you have, please list the name of ALL injections and/or medications that you can recall, and approximately when your last dose was:*
IF RE-ORDERING WEIGHT MANAGEMENT MEDICATION please list your current medication name and the dose you are taking:*
IF RE-ORDERING WEIGHT MANAGEMENT MEDICATION please select your current medication name and the dose you are taking:

Semaglutide 10 units once weeklySemaglutide 20 units once weeklySemaglutide 30 units once weeklySemaglutide 40 units once weeklySemaglutide 50 units once weeklyTirzepatide 2.5 mg once weeklyTirzepatide 3 mg once weeklyTirzepatide 4 mg once weeklyTirzepatide 5 mg once weeklyTirzepatide 6 mg once weeklyTirzepatide 7.5 mg once weeklyTirzepatide 10 mg once weeklyN/A - I am not re-ordering weight management medication
Have you had a nutrition and fitness consult with our health coach, David yet?*

YesNo
IF RE-ORDERING WEIGHT MANAGEMENT MEDICATION do you want to stay on the same dose you are currently on, or do you plan to continue titration to a higher dose? PLEASE NOTE: 10mg of Tirzepatide and 50 units of Semaglutide are the MAXIMUM dosages available at this time.*

I want to stay on the same doseI want to increase my doseI want to decrease my doseN/A - I am not re-ordering weight management medication
Height:*
Weight:*
BMI Calculator (duplicate information, but is a necessary calculation)*
Do you have a primary care provider? (Includes NPs and PAs)*

YesNo
Primary Care Provider Name (if applicable):
Are you Pregnant or Breastfeeding?*

YesNoNot Applicable
I understand that GLP-1 medications may disrupt oral contraceptive efficiency, and that I will need to use a barrier method for four weeks upon beginning and upon each dose escalation.*

YesNot Applicable
Code Status:*

Full CodeLimited ResuscitationDo Not Resuscitate (DNR)
Please list ALL allergies that you are aware of:*
Please select all applicable past or present medical conditions listed below, if any:*

Diabetic RetinopathyThyroid CancerGallbladder DiseaseAcute Inflammation of PancreasDecreased Kidney FunctionMultiple Endocrine Neoplasia Type 2Family History of Medullary Thyroid CarcinomaKidney Disease with Likely Reduced Kidney FunctionAllergy to Sulfa MedicationsHypoglycemiaDiabetesHypertensionAsthmaLow Potassium LevelLebers DiseaseNone of the Above
Please list ALL medical conditions you have been diagnosed with:*
Has anyone ever told you your kidneys or liver do not function properly?*

YesNo
Please list ALL medications with dosages and/or supplements you are currently taking: *
Please list any surgical procedures you have had previously:*
Please provide a brief description of your current health and wellness goals:*
Are you employed currently?*

YesNoI am retiredI am disabledSelf-employed
If working, what type of work do you do? Do you ever work night-shift?*
Are you currently or have you ever been a smoker? (Includes vaping)*

Never smokerFormer smokerCurrent smokerTrying to quit
Are you in recovery from substance use and/or alcohol use disorder?*

YesNo
Do you consume alcohol?*

No alcohol consumptionOccasionalModerateHeavy
If you consume alcohol, how much and how often? This is important because alcohol can affect the way that your body responds to medication, as well as your overall weight management goals.*
Do you use any substances that may alter the mind and/or body in any way? (Includes CBD, Delta Products, Kava, Kratom, Marijuana)*

YesNoSometimes
How much caffeine do you have on a daily basis? (coffee, soda, tea, energy drinks, etc.)*
How much caffeine do you have on a daily basis? (coffee, soda, tea, energy drinks, etc.)*
What is your stress level currently (0-10 scale), and how do you manage stress? This is important because increased stress leads to cortisol and inflammatory changes in the body which can affect weight management. *
Approximately how many hours do you sleep per night? Do you wake feeling well rested?*
How active are you?*

Not ActiveSomewhat ActiveModerately ActiveVery Active
Do you have any physical limitations that make exercise difficult for you?*
How many times per week do you work out intentionally?*

None currently1 day per week2-3 days per week4-5 days per week5+ days per week
What does your physical activity look like? (cardio, weights, yoga, biking, etc.)*
What type of diet do you currently follow?*

Regular - No RestrictionsCarnivorePaleoPescatarianVegetarianVeganCalorie RestrictedCarbohydrate RestrictedKeto DietIntermittent Fasting
How much water do you drink daily?*
Acknowledgement of Understanding Regarding Wellness Shop Items and Orders
I understand that Coastal Wellness NC does NOT replace routine care of a Primary Provider:*

Yes
I understand that along with the benefits of any medical treatment or therapies, there are both risks and potential complications to treatment, as well as not being treated. Those risks and potential complications have been explained to me. I have not been promised or guaranteed any specific benefit from the administration of these therapies and no warranty or guarantee has been made regarding the results of treatment. I agree to proceed with treatment and to comply with recommended dosages.*

Yes
I agree to comply with requests for ongoing testing to assure proper monitoring of my treatments that may include laboratory evaluation of all aforementioned hormone levels and/or other diagnostic testing by my primary care physician, or other specialist.*

Yes
I agree to see my primary care physician, gynecologist, or other practitioner for regular monitoring and for preventative measures that may include but are not limited to complete physicals, rectal examinations and/or colonoscopy, EKG, mammograms, pelvic/breast exams, pap smears, prostate exams, PSA levels, etc. at least on a yearly basis. I agree to immediately report to my physician any adverse reaction or problem that might be related to my regimen with CWNC.*

Yes
I certify that I have read or have had this form read to me, and that I understand its contents. I agree not to undergo any treatments unless I fully understand the treatment and have discussed possible risks, benefits, and side effects with the provider. I agree to receive the treatment that has been recommended to me.*

Yes
I agree all the above health information submitted on the questionnaire is complete and accurate.*

Yes
I have read and understood the terms of this agreement*

Yes
What product(s) are you ordering from the Wellness Shop? We will use this section to generate charges in your patient specific Athena Health record for payment and completion of your order. Once charges have been entered, you will be contacted by phone to collect payment OR you can make payment through your patient portal. If you are a NEW weight management patient and have not had your initial telehealth consult yet, please select "awaiting consult."*

Awaiting ConsultSemaglutide - 1 vial ($520)Semaglutide - 2 vials ($870)Anti-Wrinkle Cream ($110)Lipo-Trim SL Spray ($175)MICC (Methionine, Inositol, Choline, Cyanocobalamin) IM Injections ($250)Amino Acid Blend (GACLIV) IM Injections ($150)Glutathione IM Injections ($150)Vitamin D3 IM Injections ($120)NAD+ Nasal Spray ($215)NAD+ SQ Injections ($225)CJC-Ipamorelin SQ Injections ($500)Bronze IV package (5 Targeted Infusions) ($899)Silver IV package (10 Targeted Infusions) ($1,399)Gold IV package (15 Targeted Infusions) ($2,099)
Signature*

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Initial Health Consultation Form

Required Demographic Information for your Athena Health Chart

Medical Information To Be Reviewed and Verified During Your Visit

Acknowledgement of Understanding Regarding Wellness Shop Items and Orders