Metabolic Health Consultation Intake Form
Please complete all relevant sections and provide detailed information to help us understand your health background and concerns.
Basic Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What brings you in today?
Please briefly describe your main health concerns or goals.
*
Tell Us Your Story
How long have you been experiencing these concerns?
*
Have you felt dismissed or unheard by previous healthcare providers?
*
Yes
No
What Have You Already Tried?
Please select all that you have tried previously for your health concerns.
Diet changes
Exercise
Medications
Supplements
Therapies (physical, mental, alternative)
Other
Medical History
Please check any of the following conditions you have been diagnosed with:
Diabetes
High blood pressure
High cholesterol
Thyroid disorder
PCOS
Heart disease
Other
Have you had any lab work done in the last 12 months?
*
Yes
No
Lifestyle Snapshot
How would you describe your current physical activity level?
Sedentary
Lightly active
Moderately active
Very active
Other
How would you describe your typical eating pattern?
Regular meals
Frequent snacking
Intermittent fasting
Irregular
Other
Treatment Preferences
Which types of treatment approaches are you interested in? (Select all that apply)
Lifestyle modification
Medication
Supplements
Integrative/holistic
Open to recommendations
Other
Good Fit Questions
Are you willing to make changes to your daily routine if recommended?
*
Yes
No
Maybe
Is there anything else you would like us to know?
Final
I agree to the privacy policy.
*
I agree to the privacy policy.
I understand this is not a substitute for medical advice or emergency care.
*
I understand this is not a substitute for medical advice or emergency care.
Submit
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