Medical Intake Form | Eternelle Health & Wellness

1
What is your first and last name?* This field is required.
First Name
Last Name
2
When is your birth date?* This field is required.
Date
Month
Day
Year
3
What is your gender?* This field is required.
Please Select
Please Select
Male
Female
Agender
Bigender
Genderfluid
Genderqueer
Demiboy
Demigirl
Androgynous
Two-Spirit
Pangender
Polygender
Omnigender
Neutrois
Maverique
Intergender
Third Gender
Aliagender
Graygender
Cisgender
Transgender
Non-Binary
Gender Nonconforming
Gender Variant
Gender Expansive
Feminine-of-Center
Masculine-of-Center
Questioning
Genderless
4
Let's kick things off by getting to know you!* This field is required. Don’t worry—your details are safe with us!
Please enter your email
Please enter your phone
Please Select
Please Select
Google/Search Engine
Social Media (Facebook, Instagram, Twitter, etc.)
Friend/Family Referral
Advertisement (Online/Print/TV)
Event/Conference
Email Newsletter
Blog or Article
Online Review/Recommendation
Website/Company Website
Flyer/Brochure
Radio/Podcast
Walk-In/Passing By
Word of Mouth
How did you hear about us?
5
What is your home address?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Next up, we just need your emergency contact details for safety!* This field is required.Please share the name and phone number of your emergency contact.
Enter your emergency contact's name
Enter your emergency contact's phone number
7
Are you currently pregnant, planning to become pregnant, or breastfeeding?* This field is required.
YESNO
8
Have you used any weight loss medications before?* This field is required.
YESNO
9
We’d love to know which brand you were using when you stopped, and the dose or strength you were taking at the time.* This field is required.
10
Are you currently using a weight loss medication like Semaglutide/Ozempic, Mounjaro, or something similar, and thinking about switching to our program?* This field is required.
YESNO
11
Could you share your reasons for switching?* This field is required.Reason for Switching
Huge
Large
Normal
Small
Ok
Ok
12
Where are you in the process right now regarding the switch?* This field is required.Current Stage in the Process
e.g. Consultation Scheduled, Medication Running Out, Currently Transitioning
13
Does any of the following apply to you or someone in your immediate family?Select all that apply. Skip to the next question if none apply.
Cardiac Disease
Hepatitis
HIV/AIDS
Hormone Imbalance
Skin Disease
Current Infections/Illness
Gastrointestinal Disease
Chronic Pancreatitis
Cancer
High Blood Pressure
Seizure Disorder
Leber's Optic Neuropathy
Blood Clotting
Diabetes
Thyroid Cancer
History of Pancreatic Issues
Other
14
Thanks for letting us know! Could you share a bit more about this?* This field is required.
(e.g., who is affected, when it was diagnosed, and any current treatments)
Huge
Large
Normal
Small
Ok
Ok
15
Are you currently taking any medication for these symptom/s?* This field is required.
YESNO
16
Let’s talk about how you’ve been feeling lately. Are you experiencing any of the following?Select all that apply. Skip to the next question if none apply.
Chest Pain
Hematological
Gastrointestinal
Musculoskeletal
Respiratory
Cardiac Disease
Cardiovascular
Lymphatic
Neurological
Psychiatric
Genitourinary
Weight Gain
Weight Loss
Other
17
Thanks for letting us know! Approximately when did these symptoms begin?* This field is required.
Date
Year
Month
Day
18
Have you had the chance to talk with a healthcare provider about these symptoms?* This field is required.
YESNO
19
Do you have any allergies we should know about?Select all that apply. Skip to the next question if none apply.
Food/Nuts
Lidocaine
Hydrocortisone
Shellfish/Animal Protein
Aspirin
Latex
Other
20
Are you currently taking any medication for these allergies?* This field is required.
YESNO
21
Do you use tobacco products?* This field is required.
YESNO
22
What types of tobacco products do you use, and how long have you been using them?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
23
Have you ever used or do you currently use any illegal drugs?* This field is required.
YESNO
24
How often do you consume alcohol?* This field is required.
Please Select
Please Select
daily
weekly
occasionally
never
25
What is your current weight?* This field is required.Please state it in kilograms.
26
What is your goal weight?* This field is required.Please state it in kilograms.
27
Has your weight changed much this past year? Tell us how it’s shifted.* This field is required.
I gained (in kg)
I lost (in kg)
28
Have you had bloodwork done in the last 90 days?* This field is required.
YESNO
29
Great! You can upload your bloodwork results below so our physician can review them.* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
30
We’ll connect you with a Quest Diagnostics location near you. Simply check the box below to get started!
Yes! I’d like that.No, I don't want to.
31
Before we proceed, please take a moment to review the important information about Semaglutide & Tirzepatide therapy.
32
Once you've read and understood the details, kindly check the box to confirm your consent. Your health and understanding are our top priorities!* This field is required.
33
By signing below, you’re letting us know that you’ve read and understood the treatment details. Your signature shows you’re ready to take the next step with us.* This field is required.
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