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
What is the reason for your visit? (Select all that apply)
Briefly describe your symptoms, if any.
How long have these symptoms been present?
Do you have any of the following conditions?
Please list any other conditions we should know about.
List all medications, vitamins, or supplements you are currently taking:
How would you rate your diet?
How often do you exercise?
How many hours of sleep do you get per night?
Do you have recent lab work?
Would you like help interpreting your labs?
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?
I understand this is a telehealth wellness service. Lab testing and medications (if needed) are billed separately.
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.
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