Online Wellness Checkup Form

Complimentary* Wellness Checkup Session

For a limited time, schedule a 20 minute in person or video consult. *Regularly $49.00
We are excited that you are ready to take control of your Wellness and have chosen Bayshore Pharmacy to help you in your journey.

Credit Card information is required to hold your spot at the time of booking. We believe your time is very valuable and ask that you respect our time as equally valuable. In the event you schedule a strategy session (free) or appointment (paid) with us, and you fail to cancel/reschedule, we will process a $49 late/no-show fee for our time and effort for the preparation for our session.
Full Name*

First NameLast Name
Phone Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail*
example@example.com
Birth Date*

MonthDayYear
Date
Gender*

MaleFemale
Appointment*
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Preferred Meeting Type
Your credit card will not be billed for your complimentary session if you attend. In the event you schedule a strategy session (free) or appointment (paid) with us, and you fail to cancel/reschedule, we will process a $49 late/no-show fee for our time and effort for the preparation for our session.
Health History
Height (feet/inches)*
Weight (pounds)*
Are you currently taking any medications or supplements?*

YesNo
If yes, please specify
Do you have any existing medical conditions?*

YesNo
If yes, please specify
Have you had any recent surgeries or medical procedures?*

YesNo
If yes, please specify
Check all HEALTH CONDITIONS that apply to you:*

NONEAcneAlcohol ConsumptionAllergiesAlzheimer's DiseaseAnemiaAnxietyArthritisAsthmaBack PainBladder InfectionHigh Blood PressureCaffeine ConsumptionCaffeine SensitivityCalcium DeficiencyCancerCeliac DiseaseChronic ConstipationChronic FatigueChronic SinusitisCirculation (poor)ColitisCongestive HeartFailureDepressionDiabetes Type OneFibromyalgiaGall Bladder DiseaseGall StonesGoutHeartburnHeart DiseaseHerniaHigh CholesterolHyperactiveHypoglycemiaInsomniaIrritable Bowel SyndromeKidney DiseaseKidney StonesLow EnergyLow Sexual StaminaLupusMenopausalMigraine HeadachesMood SwingsMultiple SclerosisNursing MotherPregnantPremenstrual SyndromeOsteoporosisSleep DisorderSmokingStressHigh TriglyceridesWater Retention/BloatingUlcersDiabetes Type Two
Do you have any allergies?*

YesNo
If yes, please specify
Lifestyle Habits
Dietary Habits*

BalancedVegetarianVeganGluten-freeOther
Exercise Routine*

SedentaryLight ExerciseModerate ExerciseIntense Exercise
Sleep Patterns*

RegularIrregularInsomniaOther
Stress Level*

LowModerateHigh
Wellness Goals
What is your biggest challenge right now as it pertains to achieving your health goals? (What keeps you up at night?)*
How long have you been dealing with this?*
How does it affect you?*
Who else around you does it affect?
What other programs/products have you tried in the past?
How many times a day do you eat?*
How many GLASSES / OUNCES of water do you drink daily?*
What do you do during your days for exercise?*
Do you have pains? What do you do/take that helps?*
Additional Comments or Questions
Date

MonthDayYear
Date
Should be Empty:

Complimentary* Wellness Checkup Session

Health History

Lifestyle Habits

Wellness Goals