This comprehensive intake captures your complete health history to personalize your optimization protocol.
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.
How did you hear about us?
Body Composition Section
This section gives us a snapshot of how much of your body is made up of fat versus muscle and other tissues, helping us tailor your wellness plan.
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
Your medical history gives us key insights into past conditions, treatments, or surgeries, so we can factor them into your care.
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
Primary Health Goals
We ask you to pick your top three health goals—like improving energy, losing weight, or reducing stress—so we can focus on what matters most to you and customize your plan around those priorities.
Select your primary health goals
*
Fat Loss
Muscle Gain
Energy Optimization
Sleep Improvement
Hormone Optimization
Cognitive Enhancement
Longevity
Athletic Performance
Stress Reduction
Sexual Health
Current Medications and Supplements
Listing your current medications and supplements helps us avoid interactions and ensure any wellness recommendations are safe and aligned with what you're already taking.
Current medications with dosages
*
Current supplements with dosages
*
Domain Symptom Checklist
The symptom checklist allows you to highlight any physical or emotional symptoms you experience. You'll rate each symptom from 0 (none) to 5 (severe), so we can focus on what’s most impactful and track your improvements over time.
Metabolic Domain
The metabolic domain looks at things like energy levels, appetite, digestion, and other bodily functions that relate to your metabolism, helping us support your body’s balance and overall energy.
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
The inflammatory domain covers symptoms like aches, swelling, or other signs of inflammation. By understanding these, we can help reduce discomfort and support your body’s recovery.
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
The hormonal domain looks at signs that might relate to hormone balance—like mood changes, sleep issues, or menstrual patterns. By spotting these, we can help support your body’s natural rhythms.
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
The thyroid domain checks for symptoms that might point to an overactive or underactive thyroid, like changes in energy, weight, or temperature sensitivity, so we can keep your metabolism on track.
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
The adrenal domain looks at stress-related symptoms, like fatigue or feeling wired. It helps us understand if your body’s stress response might need some support.
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
The sleep domain focuses on how well you’re resting—like if you’re having trouble falling asleep, staying asleep, or waking up refreshed. It helps us identify ways to improve your sleep quality.
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
The cardiovascular domain focuses on symptoms like heart rate, circulation, or blood pressure concerns, helping us keep your heart health in check.
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
The gut domain addresses digestion-related symptoms, like bloating, discomfort, or irregularity, so we can support your digestive health and overall wellness.
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
The neurological domain looks at symptoms like headaches, memory issues, or tingling sensations. It helps us understand any nervous system concerns to better support your overall brain and nerve health.
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
The mitochondrial domain focuses on your cellular energy—things like fatigue or stamina. It helps us see if your cells are producing energy effectively, so we can help optimize your vitality.
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
The immune domain looks at symptoms like frequent illness, allergies, or inflammation. It helps us understand how your immune system is functioning, so we can support it better.
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
The sleep domain broadly looks at your overall sleep quality—like if you feel rested or have trouble staying asleep. In contrast, the sleep/nighttime domain zeroes in more on nighttime-specific issues—like difficulty falling asleep or waking frequently—so we can target solutions for those nighttime disruptions.
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
The exercise profile gives us a picture of your activity levels, from what types of exercise you do to how often you move. This helps us design a plan that fits your lifestyle and goals.
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
The nutrition profile looks at your eating habits—what you eat, how often, and any dietary preferences. It helps us create a plan that aligns with your goals and nutritional needs.
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 Availability
We adhere strictly to HIPAA compliance and prioritize your privacy. While some patients have shared their bloodwork through email, please note that email is not a HIPAA-compliant method of communication. We will always safeguard your information to the highest possible standards. Ultimately, it is your choice if you wish to submit protected health information in this way, and we’re happy to discuss secure alternatives if preferred.
Do you have recent lab results (within 6 months)?
Please Select
Yes
No
Lab panels available
CBC
CMP
Lipid Panel
Thyroid Panel
Hormone Panel
Vitamin D
Other
None
Summary of Lab Results
Submit
Submit
Should be Empty: