FIT MIND Intake Form

FIT MIND Intake Form
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
Phone Number*
Gender
How will you be checking in?*
How did you hear about this program?
Medical History
Are you under the care of a qualified healthcare professional? Please list whom.*
What medications, supplements and over the counter items do you take regularly or are currently prescribed:*
Any past surgeries and hospitalizations?*
Personal History
How much do you weigh?
How tall are you?
Do you exercise regularly?
How many hours do you sleep?
How is your energy?
Does your energy level affect your daily activities?
Have you been treated for depression in the past?
Are you currently depressed?
How does your current weight impact your body image and mental health?
How much weight are you looking to lose?
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 fluids do you normally drink? Please approximate in ounces.
Please list all types of beverages you regularly drink.
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?
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
Suicidal Thoughts
Depressive symptoms
Anxiety/Mood Disorder
Alcohol abuse
Illicit Drug Use
Disordered Eating Pattern/Tendency
Thyroid problems
Personal or family history of medullary thyroid cancer or MEN syndrome
Diabetes (Type 1 and 2)
History of low blood sugar
Pancreatitis/Pancreas Disease
Personal history of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
Cancer
Currently undergoing cancer treatment or within the last 12 months
Gallbladder disease
Currently Pregnant or Trying to Conceive
Currently Breastfeeding
HIV/AIDS
Headache/Neurological Disorder/Fainting/Seizures
Decreased Kidney Function/ Renal Disease

What are your top preferences for checking in?

	Top choice	Works ok	Doesn't work for me
Morning (9am-noon)
Afternoon (noon-6pm)
Evening (7pm-9pm)
Weekends

Upload Valid State ID, Drivers License or Passport. NO medication prescriptions can be filled without this requirement. FRONT and BACK.

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I have read the following documents (are in the pdf version of this intake), fully understand them and agree to their terms (please sign with your cursor below). Documents: Rules & Responsibilities, Acknowledgement and Consent to Privacy Practices and Consent to Limited Treatment.*

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FIT MIND Intake Form

General Information

Medical History

Personal History

Diet and lifestyle

Let's get a current picture of your health