Intake Form

Intake Form
Help us personalize your care! This brief survey gathers key details for comprehensive health screenings, focusing on chronic disease management. Your input guides our approach to better meet your unique health needs. Thank you for taking a moment for your well-being.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Email
example@example.com
MaleFemale
Medical History
Do you have any existing medical conditions? Please specify.
List any surgeries or significant medical procedures you have undergone.
Family Medical History
Are there any chronic diseases prevalent in your immediate family? Please provide details.
Lifestyle and Habits
Describe your typical daily diet.
How often do you engage in physical activity or exercise?
Substance Use, Smoking, and Alcohol Consumption
Do you currently use tobacco, marijuana, or any other substances? If yes, please specify the type and frequency.
Do you currently smoke? If yes, how many cigarettes per day?
How often do you consume alcoholic beverages, and in what quantities?
Mental Health
Have you experienced high levels of stress or anxiety recently?
Do you have a history of mental health concerns?
Medication and Supplements
List any current medications or supplements you are taking.
Have you experienced any side effects from your medications?
Screening Tests
When was your last comprehensive health screening?
Have you had any specific tests related to chronic disease management? Please provide details.
Weight and BMI
What is your current weight and height?
Are you actively trying to manage your weight?
General Well-being
How would you rate your overall well-being on a scale of 1 to 10?
Is there anything else you would like to share about your health that may be relevant?
Should be Empty:

Intake Form

Medical History

Family Medical History

Lifestyle and Habits

Substance Use, Smoking, and Alcohol Consumption

Mental Health

Medication and Supplements

Screening Tests

Weight and BMI

General Well-being