naturalwellness360.com - General Candidate Intake Form

General Candidate Intake Form
To ensure you are eligible for the programs offered and to rule out any health risks with particular therapies, please complete the following questionnaire. During your consultation, we will go through this form and determine the best course of care. In the event the sought-out interventions do not prove to be suitable, we will discuss other solutions with you.
Name
Date

MonthDayYear
Date
Age
Date of birth

MonthDayYear
Date
MaleFemale
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Phone #
Please enter a valid phone number.Format: (000) 000-0000.
CellLand line
YesNo
YesNo
I Name consent to allow Rosemarie Phillip, MD and/or Nina Stout, CNS, to speak with me and perform an examination (if necessary) to determine if I am a good candidate for this program.
What are your primary health and/or aesthetics concerns?
What approaches have you tried for addressing these concerns?
Please explain your current eating plan/diet and any challenges you face in maintaining a healthy program:
YesNo
If no, why not?
If yes, what form(s)?
What limitations do you experience, if any?
What surgeries or health limiting injuries have you experienced:
YesNo
If yes, please explain:
YesNo
If yes, please explain:
YesNo
If yes, please explain:
YesNo
If yes, please list medications:
Please list any current medications other than those already listed above:
Please list supplements you are currently taking:
HORMONE HEALTH FOCUS:
Brain fogWeight gainSleep issuesExcess Hair GrowthLow StaminaMood FluctuationsLow libidoLonger Recovery Time After WorkoutsLow MoodAcneHair LossSkin laxity/thinnessDecreased Muscle MassAnxietyIrritability
FOR WOMEN
YesNo
If not, when did you last have a period?
Vaginal drynessHot flashesNight sweatsIrregular CyclesBreast TendernessTrouble reaching climaxHeavy Periods
FOR MEN
Inability to Achieve ErectionTrouble maintaining an erectionDecrease in morning erectionsPremature ejaculationInability to EjaculateEnlargement of Breast Tissue
WEIGHT LOSS FOCUS: (if applicable)
Current height:
Current weight:
Goal weight:
Goal time frame for weight loss:
YesNo
If yes, please explain:
What methods for weight loss have you tried in the past?
YesNo
If yes, please explain:
Are you currently experiencing any extreme stress in your personal life?
Do you foresee any upcoming stressors or travel in the next 3 months?
Do you have other health concerns or questions about integrative/functional/regenerative medicine you would like to discuss with the practitioners?
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General Candidate Intake Form

HORMONE HEALTH FOCUS:

FOR WOMEN

FOR MEN

WEIGHT LOSS FOCUS: (if applicable)