Vitality Wellness Intake Form
Please complete this to the best of your ability 24 hours prior to your appointment. This allows proper time for review prior to our meeting.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Appointment preference
*
In person
Virtual
Primary Wellness Goals
Weight Loss
Energy
Hormone Balance
Gut Health
Inflammation
Longevity
What prompted you to seek support?
Top 3 symptoms you are experiencing:
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Current Weight
*
Goal Weight
Highest Weight
Weight changes in the last 12 months?
Have you tried weight loss before?
*
YES
NO
If YES, what has worked or did not work for you?
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Do you experience the following?
*
Constant hunger
Late night eating
Sugar cravings
Carb cravings
None
Energy Dips (select time)
Morning
Afternoon
Evening
Do you track your protein intake?
*
Yes
No
Estimated daily protein intake (in grams) if known
How much water do you drink daily?
*
How many meals per day?
Do you eat breakfast?
*
Exercise frequency
*
Daily
2-3 times per week
1 per week
Rarely
Never
Type of exercise
Sleep quality (1 poor - 10 excellent)
*
Stress level (1 none - 10 extremely stressful)
*
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Hormonal Symptom Review Please select any symptoms you are currently experiencing:
Irregular menstrual cycles
Shortened or lengthened cycles
Missed periods
Hot flashes
Night sweats
Mood swings
Increased anxiety
Irritability
Brain fog / difficulty concentrating
Memory changes
Fatigue / low energy
Sleep disturbances / waking at night
Weight gain (especially midsection)
Difficulty losing weight
Decreased libido
Vaginal dryness
Hair thinning or hair loss
Dry skin
Joint pain or stiffness
Headaches or migraines
Increased PMS symptoms
None of the above
Please select any of these that apply to you:
*
Stroke
Seizure disorder
Heart disease
History of heart attack
Hypertension (high blood pressure)
High cholesterol
Clotting disorder
Diabetes
Thyroid disorder (hypothyroid, hyperthyroid)
Liver disease
Kidney disease
Cancer (current or history of)
Multiple Endocrine Neoplasia Type 2 (MEN2)
Food allergies
None of the above
Medical Weight Loss Screening (GLP Eligibility Review)
*
Personal history of medullary thyroid cancer
Family history of medullary thyroid cancer
History of Multiple Endocrine Neoplasia syndrome type 2 (MEN2)
History of pancreatitis
Gallbladder disease or gallstones
Severe gastrointestinal disease (gastroparesis, delayed stomach emptying, etc.)
Kidney disease
Liver disease
Type 1 diabetes
Currently pregnant or planning pregnancy
Currently breastfeeding
History of eating disorder
None of the above
Have you previously used GLP-1 medications (such as semaglutide or tirzepatide)?
YES
NO
What was your experience?
Have you experienced any of the following symptoms?(nausea, vomiting, severe abdominal pain, reflux, etc.)
GI Symptoms:
Bloating
Constipation
Diarrhea
Indigestion
Other
Current medications:
Do you have any allergies to medicine?
Hormone history?
Previous Labs?
YES
NO
What would you say has held you back in the past?
What would success look like for you in the next 3 months?
Are you ready to make changes to your routine?
I understand this is a wellness program and not a substitute for medical care
Continue
Continue
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