True Wellness™ Client Intake & Safety Disclosure
Welcome to True Wellness™ This intake is required for access to any advanced wellness research offerings. We take safety seriously. Incomplete or inaccurate information may result in delayed processing or restricted access.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
DOB
-
Month
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Day
Year
Date
State Of Residence
Age Confirmation Checkbox
I confirm I am 18 years or older
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Honesty & Responsibility Acknowledgment
Required checkboxes (all must be checked):
I certify the information I provide is true, complete, and accurate to the best of my knowledge.
I understand that withholding or falsifying medical or family history may increase risk.
I agree that True Wellness may restrict or deny access based on this intake or biomarker patterns for safety.
INITIALS
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Emergency / Not Medical Care Disclosure
Required checkbox:
I understand True Wellness is not a medical clinic, does not provide emergency services, and this intake is not medical care.
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Personal Medical History
Have you ever been diagnosed with, treated for, or told you may have any of the following? (Select all that apply)
Current or past cancer
Unexplained lumps, abnormal imaging, or pending biopsy
Autoimmune disease (e.g., lupus, RA, MS, IBD)
Cardiovascular disease (heart attack, CAD, CHF)
Stroke / TIA
Blood clotting disorder or history of DVT/PE
Kidney disease or reduced kidney function
Liver disease (hepatitis, cirrhosis, elevated liver enzymes)
Thyroid disorder
Diabetes (Type 1 or 2) / prediabetes / insulin resistance
Pancreatitis history
Gallbladder disease
Seizure disorder
Severe anxiety/panic, bipolar disorder, psychosis
Pregnant / breastfeeding / trying to conceive
None of the above
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Cancer Details (Conditional)
Type Of Cancer
Year Diagnosed
Current Status
Active Treatment
Remission
Unsure
Required checkbox:
I understand certain research categories may be restricted based on cancer history.
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Pregnancy / Breastfeeding? Yes/ No
For safety reasons, True Wellness cannot provide research access to individuals who are pregnant, breastfeeding, or actively trying to conceive.
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Kidney/Liver Details (Conditional)
Have you ever been told your kidney function is reduced? (Yes/ No)
Have you had abnormal liver labs in the past 12 months? (Yes/No)
Are you under current care for kidney/liver issues? (Yes/No)
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Mental Health Sensitivity (Conditional)
Do you have a history of panic attacks or severe anxiety? (Yes/No)
Have you ever had a manic episode or bipolar diagnosis? (Yes/No)
Are you currently taking psychiatric medications? (Yes/No)
Required checkbox:
I understand certain stimulatory research categories may be restricted for safety.
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Medications + Allergies
Medication
Are you currently taking prescription medications? (Yes/No)
If Yes → list medication names + doses
Allergies
Any known medication allergies? (Yes/No)
If Yes → list
Prior adverse reactions:
Have you ever had adverse reactions to IV vitamins, NAD products, peptides, stimulants, or injections? (Yes/No)
If Yes → describe
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Family Medical History
Family history matters. Please answer carefully.
Checkboxes (select all that apply):
Cancer in a first-degree relative (parent/sibling/child)
Early heart disease or stroke (<60 years)
Type 2 diabetes
Thyroid disease
Dementia / Alzheimer’s
Blood clot disorders
Unknown / adopted / unsure
None of the above
Follow-up (conditional):
If any selected (except none/unknown):
Which relative(s)?
Approximate age of diagnosis
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Goals + Baseline
Choose primary goal
Body composition / metabolic optimization
Recovery / performance
Sleep / stress resilience
Skin / hair / anti-aging
General wellness baseline
Other
Lifestyle
Sleep average (Per Night)
Stress level (High/ Moderate/ Low)
Exercise frequency (Per Week)
Alcohol frequency (Per Week)
Tobacco / nicotine (Yes/No)
Stimulant use (High / Moderate / Low)
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Lab Consent + Data Use
Required checkboxes:
I consent to purchase and complete the True Wellness biomarker panel.
I understand lab results are used to generate educational wellness insights, not medical advice.
I understand access may be restricted based on disclosed history or biomarker patterns.
I consent to True Wellness storing my intake + lab insights in a secure system to personalize my experience.
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REFERRAL
Jessica Countz
Brieanna Leal
Brian Davis
Gabe Trujillo
Heather Harrold
Holiday Schaldach
True Wellness Readiness Results File Upload
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Legal Terms
Required checkbox:
I acknowledge True Wellness does not diagnose, treat, cure, or prevent disease. Information provided is educational only.
I understand any compounds referenced are for research/educational discussion and not intended for human consumption.
I agree to hold True Wellness harmless for decisions I make based on educational content.
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