Jahan's Wellness Lounge Telehealth Intake

1
Full Legal Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Mobile Phone Number* This field is required.
Please enter a valid phone number.
4
Email Address* This field is required.
example@example.com
5
Street Address* This field is required.
6
City* This field is required.
7
State* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other
8
ZIP Code* This field is required.
9
California Location Verification* This field is required.
I confirm I am physically located in California at the time of this consultation
10
Current height - feet* This field is required.
11
Current height - inches* This field is required.
12
Current weight (lb)* This field is required.
13
Medical history* This field is required.
High Blood Pressure / Hypertension
History of Heart Attack, Stroke, or Heart Disease
Glaucoma
Hyperthyroidism
History of Drug or Alcohol Abuse
Currently Pregnant, Planning to Become Pregnant, or Breastfeeding
Currently Taking an MAO Inhibitor (within past 14 days)
None of the above apply to me
14
Current medications and dosages
15
Known drug allergies
16
California Telehealth Informed Consent & Financial Agreement* This field is required.
17
Electronic Legal Signature* This field is required.
18
Date of Signature* This field is required.
Date
Month
Day
Year
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