Intake Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Other
Email
example@example.com
Phone Number
Please enter a valid phone number.
Preferred Method of Contact
Please Select
Call
Email
Text
Emergency Contact Name and Phone
REASON FOR INQUIRY
What brings you to Summit today?
How did you hear about Summit?
Social Media
Event
Referral
Other
Medical History Snapshot
Current Medications, Vitamins and Supplements
Allergies
Medical Conditions
Heart Disease/High Blood Pressure
Diabetes
Thyroid Disorder
Cancer (past or present)
Liver or Kidney Disease
Depression or Anxiety
Other
Any surgeries or hospitalizations in the past 5 years?
Are you currently pregnant, nursing, or planning pregnancy?
Are you currently under care of another specialist (endocrinologist, OB/GYN, etc.)?
Lifestyle & Health Factors
Height
Weight
Typical Daily Activity Level
Please Select
Active
Moderate
Sedentary
Tobacco or nicotine use?
Yes
No
Alcohol Use?
Never
Occasionally (1–2 drinks per month)
Socially (1–2 drinks per week
Regularly (3–5 drinks per week)
Daily or almost daily
Recreational drug or anabolic steroid use?
Yes
No
Sleep quality?
Poor
Fair
Good
Excellent
Stress Level?
Low
Moderate
High
Nutritional Habits?
Balanced
Irregular
Special diet (keto, vegan, etc.)
Symptom Screening
Have you experienced any of the following recently?
Fatigue or low energy
Weight gain / difficulty losing weight
Low libido
Mood swings / irritability
Brain fog / memory issues
Hair Issues: loss/thinning/dry/brittle
Poor sleep
Hot flashes or night sweats
Irregular or absent menstrual cycles
Erectile dysfunction or decreased performance
Goals & Readiness
What are your top 3 health goals?
Are you comfortable doing regular labs and follow-up visits?
How ready are you to commit to making lifestyle or treatment changes?
Ready - Let's Go
Still Considering It
Not Ready
Other
Consent & Acknowledgements
Please review and acknowledge the following consents to help us proceed with your intake.
Acknowledgements: ✅ Please check each box below to confirm your acknowledgment
*
I acknowledge that I have reviewed (or will review) the HIPAA Privacy Notice and understand how my information may be used or disclosed for treatment, payment, and operations.
I consent to be contacted by Summit Hormones via phone, text, or email regarding appointments, lab results, or care coordination.
I understand and agree that completing this intake form is an initial screening only and does not constitute a medical diagnosis, prescription, or treatment plan.
I consent to receive educational updates, wellness tips, and promotional information from Summit Hormones. (You can unsubscribe anytime.)
Signature (required to confirm your consent)
*
By signing below, I confirm that the information provided is true and that I have read and understood the above acknowledgments.
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