Lifelong Balance Intake Form

Lifelong Balance Intake Form

By signing below, you confirm that the information provided is accurate to the best of your knowledge and understand that program recommendations may require clinical review, lab evaluation, and follow-up monitoring.By signing below, you confirm that the information provided is accurate to the best of your knowledge and understand that program recommendations may require clinical review, lab evaluation, and follow-up monitoring.Please provide your personal and health information to help us understand your needs.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Do you have any known allergies?
Are you currently taking any medications?
Please list any medical conditions you have (e.g., diabetes, hypertension, thyroid issues)
What are your primary wellness goals?*
How did you hear about Lifelong Balance?

Medical History, Symptoms, and Lifestyle
Please list any medical conditions you have (e.g., diabetes, hypertension, thyroid issues)
Please list any prior surgeries, procedures, or hospitalizations

Lifestyle, Readiness, Consent, and Goals
Please answer the following questions so our clinical team can assess your lifestyle patterns, treatment readiness, and support needs for the Lifelong Balance weight-loss and wellness program.
Describe your typical daily eating pattern, including meals, snacks, and timing
Do you have concerns about late-night eating, emotional eating, or cravings?
How many alcoholic drinks do you typically have in a week?
How much water do you typically drink in a day?
What is your current exercise routine, including frequency and type?
Do you have any injuries, pain, or physical limitations that affect exercise?
How many hours do you sleep on average, and how would you rate your sleep quality?
How would you rate your current stress level, and what are your main sources of stress?
Are you open to completing labs and follow-up monitoring if recommended?
If clinically indicated, are you comfortable with self-injection?
What is your preferred route when appropriate: oral, topical, nasal, or injection?
Are you willing to track your weight, symptoms, and any side effects during the program?
What has been the biggest obstacle to reaching your health or weight-loss goals in the past?
Signature
What support do you need most from the Lifelong Balance clinical team to help you succeed?
Date signed

MonthDayYear
Date
Should be Empty:

Medical History, Symptoms, and Lifestyle