Integrated Wellness Optimization Intake
Concierge Medical Evaluation and Personal Optimization Profile Designed to help our clinical team build your personalized protocol. Not for emergencies; please call emergency services for urgent symptoms.
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Biological Sex
*
Please Select
Male
Female
Patient Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
Body Composition and Core Symptoms
Only the most helpful body composition items and concise symptom screening are included here.
Height in inches
When entering your height, if you think in feet, simply multiply the number of feet by 12 to get inches. For example, 5 feet equals 60 inches. Just add any extra inches—so 5 feet 6 inches would be 66 inches total!
Current Weight in lbs
Waist circumference in inches
Your waist circumference is important because it helps us personalize your wellness plan. To measure it accurately, stand upright with your abdomen relaxed. Locate the top of your hip bone and the bottom of your ribcage, and wrap a measuring tape around the narrowest point between them—usually around your navel. Ensure the tape is snug but not tight, and take the measurement after you exhale. If you have any questions, we’re here to help!
Hip circumference in inches
We measure your hip circumference because it helps assess your body’s fat distribution, providing insight into your metabolic health. To measure your hips, stand with your feet together and find the widest part of your hips and buttocks. Wrap a measuring tape evenly around this widest area, keeping it parallel to the floor. The tape should be snug but not tight. Record the measurement at the meeting point, and this will give us a clearer picture of your overall health profile.
Body fat percentage if known
These measurements are helpful for tailoring your wellness plan, but if you feel unsure or uncomfortable, just let us know—we’ll assist you or find alternative ways to understand your needs. Your comfort comes first.
Target Weight (lbs)
Medical History
You may skip anything you’re unsure about unless it is marked required. Not for emergencies; please call emergency services for urgent symptoms.
Known health conditions
Type 2 Diabetes
Hypertension
Heart Disease
Thyroid Disorder
Autoimmune Disease
Cancer History
Sleep Apnea
Anxiety/Depression
PCOS
None
Family history
Heart Disease
Diabetes
Cancer
Thyroid Disorders
Autoimmune Disease
Alzheimers/Dementia
None Known
Allergies and sensitivities
Lifestyle Optimization
Sleep, stress, movement, and nutrition are summarized here for a concise wellness review.
Primary Health Goals
*
Fat Loss
Muscle Gain
Energy Optimization
Sleep Improvement
Hormone Optimization
Cognitive Enhancement
Longevity
Athletic Performance
Stress Reduction
Sexual Health
Medical History and Labs
Please share any relevant history and recent lab information you have available.
Current medications with dosages
Current supplements with dosages
Symptom Review by Domain
You may skip anything you’re unsure about unless it is marked required.
Metabolic Domain
You may skip anything you’re unsure about unless it is marked required.
Joint pain or stiffness
0
0
1
2
3
4
5
5
0 is 0, 5 is 5
Muscle aches
0
0
1
2
3
4
5
5
0 is 0, 5 is 5
Skin issues (rashes, acne, eczema)
0
0
1
2
3
4
5
5
0 is 0, 5 is 5
Swelling or puffiness
0
0
1
2
3
4
5
5
0 is 0, 5 is 5
Sugar/carb cravings
0
0
1
2
3
4
5
5
0 is 0, 5 is 5
Belly fat accumulation
0
0
1
2
3
4
5
5
0 is 0, 5 is 5
Midday energy crash
0
0
1
2
3
4
5
5
0 is 0, 5 is 5
Difficulty losing weight
0
0
1
2
3
4
5
5
0 is 0, 5 is 5
Increased hunger
0
0
1
2
3
4
5
5
0 is 0, 5 is 5
Excessive thirst
0
0
1
2
3
4
5
5
0 is 0, 5 is 5
Inflammatory Domain
You may skip anything you’re unsure about unless it is marked required.
Frequent headaches
0
0
1
2
3
4
5
5
0 is 0, 5 is 5
Brain fog
0
0
1
2
3
4
5
5
0 is 0, 5 is 5
Low libido
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Sexual dysfunction
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Muscle loss
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Mood swings
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Hormonal Domain
You may skip anything you’re unsure about unless it is marked required.
Low motivation
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Slow recovery from exercise
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Cold intolerance
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Hair loss or thinning
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Dry skin
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Constipation
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Thyroid Domain
You may skip anything you’re unsure about unless it is marked required.
Weight gain despite effort
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Persistent fatigue
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Adrenal Domain
You may skip anything you’re unsure about unless it is marked required.
Chronic stress
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Wired but tired feeling
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Afternoon energy crash
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Difficulty falling asleep
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
3-4am waking
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Salt cravings
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Sleep Domain
You may skip anything you’re unsure about unless it is marked required.
Trouble falling asleep
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Trouble staying asleep
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Wake up unrefreshed
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Snoring or apnea signs
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Restless legs at night
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Daytime sleepiness
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Cardiovascular Domain
You may skip anything you’re unsure about unless it is marked required.
High blood pressure
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Palpitations
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Shortness of breath
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Chest discomfort
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Poor circulation
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Exercise intolerance
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Gut Domain
You may skip anything you’re unsure about unless it is marked required.
Bloating
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Gas
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Reflux or heartburn
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Irregular bowel movements
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Food sensitivities
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Abdominal pain
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Neurological Domain
You may skip anything you’re unsure about unless it is marked required.
Brain fog
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Poor memory
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Anxiety
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Depression
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Numbness or tingling
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Dizziness
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Mitochondrial Domain
You may skip anything you’re unsure about unless it is marked required.
Chronic fatigue
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Poor exercise recovery
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Muscle weakness
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Temperature sensitivity
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Mental exhaustion
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Low stamina
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Immune Domain
You may skip anything you’re unsure about unless it is marked required.
Frequent illness
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Slow healing
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Allergies
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Autoimmune symptoms
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Swollen lymph nodes
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Chronic inflammation
None
0
1
2
3
4
Severe
5
0 is None, 5 is Severe
Sleep Night-Time Domain
You may skip anything you’re unsure about unless it is marked required.
Average sleep hours per night
Please Select
Less than 5
5-6
6-7
7-8
8-9
More than 9
Sleep quality
1
2
3
4
Best
5
1 is , 5 is Best
Typical bedtime
Hour Minutes
AM
PM
AM/PM Option
Typical wake time
Hour Minutes
AM
PM
AM/PM Option
Current Stress Level
1
2
3
4
Best
5
1 is , 5 is Best
Exercise Profile
You may skip anything you’re unsure about unless it is marked required.
Activity level
Please Select
Sedentary
Lightly Active
Moderately Active
Very Active
Extremely Active
Training types
Strength Training
Cardio
HIIT
Yoga/Flexibility
Sports
Walking
None
Training days per week
Please Select
0
1
2
3
4
5
6
7
Average session duration
Please Select
Less than 30 min
30-45 min
45-60 min
60-90 min
Over 90 min
Nutrition Profile
You may skip anything you’re unsure about unless it is marked required.
Current eating pattern
Please Select
Standard American Diet
Mediterranean
Keto/Low-Carb
Paleo
Vegetarian
Vegan
Intermittent Fasting
Other
Estimated daily protein intake
Please Select
Low (under 50g)
Moderate (50-100g)
High (100-150g)
Very High (over 150g)
Unsure
Lab Information
You may skip anything you’re unsure about unless it is marked required.
Do you have recent lab results (within 6 months)?
*
Please Select
Yes
No
Summary of Lab Results
Lab panels available
CBC
CMP
Lipid Panel
Thyroid Panel
Hormone Panel
Vitamin D
Other
None
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Any missing required fields will be highlighted before submission.
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Authorization and Acknowledgment
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