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
Sex

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.
Type:

CellLand line
Ok to text:

YesNo
May we leave a voice mail message for you?

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:
Are you able to participate in physical activity?

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:
Do you experience any chronic or debilitating pain?

YesNo
If yes, please explain:
Do you currently have or have you ever been diagnosed with any form of cancer?

YesNo
If yes, please explain:
Do you have or have you ever had issues with gallbladder, gout, diabetes, or fibroids?

YesNo
If yes, please explain:
Are you currently on any medications to treat blood pressure or diabetes?

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:
Are you currently experiencing

Brain fogWeight gainSleep issuesExcess Hair GrowthLow StaminaMood FluctuationsLow libidoLonger Recovery Time After WorkoutsLow MoodAcneHair LossSkin laxity/thinnessDecreased Muscle MassAnxietyIrritability
FOR WOMEN
Are you still having a menstrual cycle?

YesNo
If not, when did you last have a period?
Are you currently experiencing:

Vaginal drynessHot flashesNight sweatsIrregular CyclesBreast TendernessTrouble reaching climaxHeavy Periods
FOR MEN
Are you currently experiencing:

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:
Have you consulted with another practitioner for help with weight loss?

YesNo
If yes, please explain:
What methods for weight loss have you tried in the past?
Have you ever been diagnosed with an eating disorder?

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?
Signature
Should be Empty:

General Candidate Intake Form

HORMONE HEALTH FOCUS:

FOR WOMEN

FOR MEN

WEIGHT LOSS FOCUS: (if applicable)