Wellness Intake Questionnaire

Wellness Intake Questionnaire

Please complete this comprehensive assessment to help us personalize your wellness plan.
Personal Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Age
Sex

Other
Height
Weight
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Shipping Address

Street Address

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

First NameMiddle NameLast Name
Primary Goals
Primary wellness goals

Other
Other goal details
Weight management focus areas

Other
Energy support priorities

Other
Hormone balance priorities

Other
Sleep support priorities

Other
Gut health priorities

Other
Stress and anxiety support priorities

Other
Mental clarity and focus priorities

Other
Skin, hair, and nail support priorities

Other
Longevity and wellness optimization priorities

Other
Immune support priorities

Other
Performance and recovery priorities

Other
Libido support priorities

Other
GLP-1 support priorities

Other
Symptoms Assessment
Fatigue
Brain fog
Poor sleep
Low motivation
Anxiety
Mood swings
Depression symptoms
Bloating
Constipation
Diarrhea
Sugar cravings
Difficulty losing weight
Hair thinning
Dry skin
Low libido
Hot flashes
Joint pain
Inflammation
Frequent illness
Headaches
Low exercise tolerance
Poor recovery
Other symptoms
Medical History
Current medical conditions

Other
Please describe your current medical conditions
Current medications and supplements
Medication and supplement details
Medication-related considerations

Other
Please provide details for the selected medications or therapies
Allergies or sensitivities

Other
Please describe your allergies or sensitivities
Are you currently pregnant or breastfeeding?
Pregnancy or breastfeeding details
Have you ever had kidney disease?
Have you ever had liver disease?
Have you ever had cardiovascular disease?
Have you ever had diabetes or insulin resistance?
Have you ever had a thyroid disorder?
Have you ever had an autoimmune disorder?
Have you ever had cancer?
Have you ever had a gastrointestinal disorder?
Lifestyle Assessment
What best describes your typical diet?

Other
How many glasses of water do you drink per day?
How many caffeinated drinks do you typically have per day?
How often do you exercise each week?

Other
Current stress level

1

2

3

4

5

6

7

8

9

10

1 is Very low, 10 is Very high
How many hours of sleep do you get on a typical night?
Occupation
Do you work shifts or rotating hours?

Other
What are your wellness goals in your own words?
Lab Uploads
Blood Work Results

Cancelof
Hormone Testing Results

Cancelof
Functional Medicine Lab Reports

Cancelof
Current Supplement List

Cancelof
Supplement Preferences
Capsule preference
Powder preference
Vegan preference
Budget range for supplements
Interest in subscription or refill options
Preferred support option
Consent & Disclaimer
I understand that supplements may interact with medications or health conditions, and I will consult my healthcare provider before starting any new supplement.
I consent to my provider reviewing my intake information, lab uploads, and supplement preferences for wellness guidance.
Electronic Signature
Date

MonthDayYear
Date
Disclaimer acknowledgment: Please review all recommendations with your licensed healthcare provider before making changes to your routine.
Should be Empty:

Wellness Intake Questionnaire

Personal Information

Primary Goals

Symptoms Assessment

Medical History

Lifestyle Assessment

Lab Uploads

Supplement Preferences

Consent & Disclaimer