Wellness Intake-Sustain Health & Wellness

Wellness Intake-Sustain Health & Wellness

This intake helps us understand your symptoms, review your health goals, and create a personalized wellness plan tailored to you. Most patients complete this in 3-5 minutes.
Full Name*
Date of Birth*
Email Address*
Phone Number*
State of Residence*
Fatigue/low energyGeneral wellness screeningLab review (I already have labs)Other
Briefly describe your symptoms, if any.*
Less than 1 month1-3 months3-6 monthsMore than 6 months
Thyroid disorderDiabetes/prediabetesHigh blood pressureAnxiety/depressionPCOSNone
Please list any other conditions we should know about.
List all medications, vitamins, or supplements you are currently taking:
PoorFairGoodExcellent
Rarely1-2 x /week3-4 x/week5+times/week
Less than 55-66-77-88+
Yes (within last 3 months)Yes (3-12 months ago)No
YesNo
What are your main health goals?
If we could improve 2-3 things about your health in the next 3 months, what would they be?
Yes
Thank you for completing your intake!

Your next step is to submit payment to begin your personalized wellness plan.

You will receive your invoice via email or text shortly.

Once payment is completed, a licensed provider will review your information and follow up with next steps.
Should be Empty: