Health Optimization Intake Form
Welcome to Dripping Wellness! Please fill out this intake form to help us understand your health needs and preferences.
Personal Information
*
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Health History
1. Do you have any known allergies?
*
Yes
No
If yes, please specify:
2. Are you currently taking any medications (prescription or over-the-counter)?
*
Yes
No
If yes, please list:
3. Do you have any medical conditions?
*
Yes
No
If yes, please specify:
4. Have you had any surgeries in the past year?
*
Yes
No
If yes, please describe:
5. Have you ever received IV therapy before?
*
Yes
No
If yes, please provide details:
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Lifestyle Assessment
1. On average, how many hours of sleep do you get per night?
8-10 Hours
6-8 Hours
4-6 Hours
4 Hours or Less
2. Do you experience frequent fatigue or low energy?
Yes
No
3. How many days a week do you exercise?
0 times a week
1-2 times a week
3-5 times a week
5-7 times a week
If you do exercise, what type do you currently enjoy?
4. Do you currently follow a specific diet?
Yes
No
If yes, please explain.
5. How much water do you drink daily?
6. Do you consume alcohol?
Yes
No
If yes, how many drinks on average per week?
7. Do you experience high levels of stress?
Yes
No
If yes, what are your main sources of stress?
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Weight Management History
1. Have you attempted weight loss programs in the past?
Yes
No
If yes, which programs or methods?
What were your results?
2. Have you previously used weight loss medications or peptides?
Yes
No
If yes, which ones?
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Dietary Preferences
1. Do you have any dietary restrictions?
Yes
No
If yes, please explain.
2. Are there any foods you dislike or want to avoid?
Yes
No
If yes, please explain.
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Peptide Therapy History
1. Have you used peptide therapies (e.g., GLP-1, BPC-157) before?
Yes
No
If so, which one(s)?
2. Did you experience any side effects from previous peptide therapies?
Yes
No
If so , what were they?
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Treatment Goals
1. What are your primary reasons for seeking IV hydration or vitamin therapy?
*
Please Select
Rehydration
Energy Boost
Immune Support
Recovery from Illness/Surgery
Skin Health
Other
Other:
2. Have you received IV hydration or vitamin therapy before?
Yes
No
3. Are there specific vitamins or nutrients you are interested in?
*
Yes
No
If yes, list them here.
4. What is your primary reason for seeking peptide therapy?
Please Select
Increased Energy and Endurance
Reduce Inflammation and Pain Management
Weight Management and Fat Loss
Enhanced Muscle Growth and Strength
Better Metabolic Health and Insulin Sensitivity
Improved Recovery from Workouts or Injuries
Improved Gut Health and Tissue Repair
Please list any peptides you are interested here, if any?
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Current Metrics
Height:
Current Weight:
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Membership Interest
How did you hear about Dripping Wellness?
Referral
Social Media
Website
Other
Are you interested in our membership option?
Yes
No
If yes, would you like more information?
Yes
No
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Upload Your Documents
Driver License
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Labs or Pertinent Medical History
Browse Files
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Consent
Consent and AgreementI understand that IV hydration, vitamin therapy, and peptide therapy are supplemental treatments and are not a substitute for medical advice or treatment. I consent to receive these therapies based on the information provided in this form and agree to follow the recommended protocol. I will also disclose any changes in my health status to the provider.I understand that this protocol involves IV hydration, vitamin therapy, and peptide treatments in combination with diet and exercise. I agree to follow the recommendations and disclose any changes in my health status to the provider.
Patient's Signature
*
Date
*
/
Month
/
Day
Year
Date
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