Metabolic Health Intake & Care Assessment

1
Start Your Quick Pre-Screen Before Full Intake* This field is required.This form collects medical and lifestyle information to support clinical evaluation and personalized care planning. Depending on your responses and clinical review, care may be delivered through: • Messaging-based (asynchronous) care • Synchronous video consultation • Additional follow-up evaluation (if clinically necessary) All responses are reviewed by a licensed clinician.
I understand and would like to continue.
2
Are you physically located in California while completing this intake?* This field is required.Care is only available when you are physically located in California during evaluation and treatment.
Yes
No
3
Are you at least 18 years old?* This field is required.
Yes
No
4
Are you currently experiencing any of the following?* This field is required.Select all that apply
Chest pain
Severe shortness of breath
Fainting or frequent dizziness
Unintentional rapid weight loss
Severe fatigue limiting daily function
Thoughts of self-harm
None of the above
5
Are you interested in discussing medication as part of your treatment plan if clinically appropriate?* This field is required.Many prescription weight-loss medications are typically considered for patients with: • a BMI of 30 or higher OR • a BMI of 27 or higher with certain weight-related medical conditions Medication eligibility depends on multiple factors, including BMI, medical history, medication safety considerations, and clinical appropriateness after provider review. Not all patients will qualify for medication treatment. Patients who are not candidates for medication may still receive personalized recommendations and lifestyle-focused treatment options. Final treatment recommendations are determined after clinician review.
Yes
No
Unsure
6
Do any of the following apply to you?* This field is required.Select all that apply Some medications commonly used in metabolic care may not be appropriate for certain medical conditions or life circumstances. A selected response does not automatically exclude you from care, but it may affect which treatment options are appropriate and whether additional evaluation is needed.
Personal or family history of medullary thyroid cancer
MEN2 syndrome
Current pregnancy
Trying to become pregnant
Breastfeeding
Prior severe allergic reaction to GLP-1 medication
None of the above
7
Medication Limitations May Apply

Based on your responses, some medications commonly used in metabolic health treatment may not be appropriate or safe for you.

You may still continue this intake if you would like:
• Lifestyle-focused treatment recommendations
• Metabolic evaluation
• Discussion of alternative non-controlled medication options when clinically appropriate
• Clinician guidance regarding next steps

Not all patients will qualify for medication treatment.
8
Do any of the following currently apply to you?* This field is required.Select all that apply. This helps us determine whether messaging-based care is likely appropriate or whether a live visit may be safer.
Complex or rapidly changing medical conditions
Recent hospitalization (within the past 6 months)
Significant or worsening mental health symptoms affecting daily functioning
Active eating disorder symptoms
I strongly prefer live discussion with a clinician
None of the above
9
A Video Visit Will Likely Be Recommended

Based on your responses, a synchronous video evaluation may be recommended before treatment recommendations or prescribing can be finalized.

You may still continue the intake so your clinician can complete an initial assessment and determine the most appropriate next step.
10
Your pre-screening is complete. Would you like to continue with the full intake?* This field is required.You may continue even if medication options may be limited or additional synchronous evaluation may be recommended prior to treatment planning or prescribing.
Yes, continue
No, exit form
11
Please confirm the following:* This field is required.• I confirm the information I provide is accurate and complete to the best of my knowledge • I understand incomplete or inaccurate information may affect treatment recommendations and eligibility • I understand this service is not intended for emergencies • I understand submission of this intake does not guarantee prescription approval
I have read and understood the above statements.
12
Full Name* This field is required.
First Name
Last Name
13
Date of Birth* This field is required.
Date
Month
Day
Year
14
Sex Assigned at Birth* This field is required.
Female
Male
Intersex
Prefer not to say
15
Email Address* This field is required.
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code?or
Receiving the email may take a few minutes, thank you for your patience!
16
Phone Number* This field is required.
Please enter a valid phone number.
17
What are you hoping to improve or better understand?* This field is required.Tell us about your primary concerns, symptoms, goals, or challenges. Examples: weight loss resistance, insulin resistance, prediabetes, energy concerns, appetite/craving concerns, hormonal concerns, metabolic health optimization
18
What best describes how your weight or metabolic health changed over time?* This field is required.Choose the option that feels most accurate.
Gradual changes over time
Difficulty losing weight despite effort
Rapid or recent changes
Frequent fluctuations
19
Please select any conditions that apply to you.* This field is required.Select all that apply.
Prediabetes
Type 2 diabetes
PCOS
Thyroid disorder
High cholesterol or triglycerides
High blood pressure
Sleep apnea
Fatty liver disease
Anxiety
Depression
GERD/reflux
Kidney disease
None of the above
Other
20
Please describe any other medical conditions not previously listed.
21
Please list all current medical conditions.* This field is required.Include any condition you are currently monitoring or being treated for. If none, enter N/A.
22
Please list all current medications and supplements.* This field is required.Include prescription medications, over-the-counter medications, vitamins, supplements, injections, hormones, and any recent weight loss medications. If none, enter N/A.
23
Please list any medication, food, or other allergies.* This field is required.If none, enter N/A. Please include the reaction if you know it.
24
Are you currently pregnant, trying to become pregnant, or breastfeeding?* This field is required.
No
Yes, currently pregnant
Yes, trying to become pregnant
Yes, breastfeeding
Not applicable
25
Have you ever been diagnosed with or treated for an eating disorder?* This field is required.This helps us determine the safest and most supportive care pathway.
No
Yes, currently active or under treatment
Yes, past history, stable or in remission
Prefer not to say
26
Please provide any additional information you would like us to know.Examples: diagnosis, treatment history, whether symptoms are current or in remission, current treatment team, or anything you feel is important.
27
BMI CalculationPlease enter your current weight and height to calculate your BMI (body mass index). BMI value is required for intake review.
28
How has your weight changed over the past 1-5 years?* This field is required.Include major changes, life events, medication changes, pregnancies, injuries, stressors, or other factors that may have affected your weight.
29
Describe your history with dieting, structured programs, or weight-focused treatment approaches.* This field is required.Examples: calorie tracking, commercial programs, fasting, keto/low carb, meal replacements, coaching, medication, or prior medical weight loss programs.
30
Which approaches have you previously tried?* This field is required.Select all that apply.
Diet programs
Calorie tracking
Weight loss medications
Exercise programs
Structured coaching
Nothing structured
Other
31
Please describe any prior treatments, programs, or approaches you have tried.Include what helped, what did not help, side effects, barriers, or reasons you stopped.
32
What does a typical day of eating look like for you?* This field is required.Please describe your usual meals, snacks, beverages, cravings, or eating patterns.
Example: coffee in the morning, light lunch, larger dinner, evening snacks
33
Are you intentional about your protein intake?
Yes
No
Unsure
34
Do you notice any of the following eating patterns?* This field is required.Select all that apply.
Evening cravings
Stress-related eating
Frequent snacking
Strong hunger between meals
Emotional eating
Binge-like episodes or feeling out of control with eating
None of the above
35
How many days per week do you perform strength or resistance training?Examples: weights, resistance bands, bodyweight workouts
Please Select
Please Select
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
36
How many days per week do you perform cardio activity?Examples: walking, running, cycling, sports, fitness classes
Please Select
Please Select
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
37
How many hours per day are you mostly sedentary?Consider sitting, desk work, driving, screen time, or otherwise inactive time.
Please Select
Please Select
Less than 2 hours
2–4 hours
4–6 hours
6–8 hours
8–10 hours
More than 10 hours
38
How many hours of sleep do you typically get per night?Include naps if they are part of your regular sleep routine.
39
How would you rate your sleep quality?
Good (I usually wake up rested)
Fair (some difficulty falling or staying asleep)
Poor (frequent disruption or non-restorative sleep)
40
How would you describe your stress level over the past 4 weeks?Consider work, home, caregiving, finances, relationships, and overall mental load.
Low
Moderate
High
41
What would successful treatment look like for you?* This field is required.This can include health goals, symptom improvement, quality of life, confidence, energy, labs, weight-related goals, or other meaningful outcomes.
42
Which care format do you prefer if both options are clinically appropriate?* This field is required.
Messaging-based (asynchronous care)
Open to either option
Prefer video or phone visit
43
Additional Evaluation May Be Recommended

Certain responses within your intake may increase the likelihood that additional synchronous video evaluation will be recommended following clinician review to help ensure safe and appropriate treatment planning.

Final care pathway recommendations are determined after clinical review of your submitted intake.
44
Please review the following documents before continuing with intake submission and payment:

· Notice of Privacy Practices

· Privacy Policy

· Terms & Conditions

By continuing, you acknowledge that you have reviewed or had the opportunity to review these documents before submitting your intake.
45
Please review and acknowledge the following:* This field is required.• I understand messaging-based care may not be appropriate for all medical situations • I understand a clinician may recommend video or phone evaluation based on medical complexity or safety concerns • I understand treatment recommendations are based on clinical judgment and patient safety • I understand prescriptions are not guaranteed • I understand laboratory testing or medical records may be required before treatment recommendations can be finalized • I understand some patients may require synchronous video evaluation before treatment recommendations can be finalized
I have read, understood, and agree with the above statements.
46
Telehealth Consent* This field is required.• I consent to receive telehealth services, including asynchronous care when clinically appropriate • I understand telehealth has limitations compared to in-person evaluation • I understand secure electronic communication may be used for care delivery • I understand asynchronous messages may not be reviewed immediately and should not be used for emergencies or urgent medical concerns • I understand I may be asked to complete video evaluation if medically necessary • I understand I must be physically located in California during clinical evaluation and prescribing • I understand I must notify Valēre Wellness Group if I relocate outside California during active treatment. • I understand I should seek urgent or emergency care for urgent symptoms rather than using this intake • I understand failure to complete recommended follow-up evaluation may limit the ability to proceed with treatment planning or prescribing
I have read, understood, and agree with the above statements.
47
Please confirm the following:* This field is required.• I consent to receive care-related communications electronically through secure messaging, email, phone, text, or patient portal when appropriate • I understand identity verification may be required prior to prescribing or initiation of treatment • I understand prescriptions, when appropriate, will be sent to my selected pharmacy. • I understand Valēre Wellness Group does not bill insurance for clinical services; however, I may be able to use my insurance benefits for prescription medications and laboratory testing when applicable. • I understand medication and laboratory coverage, prior authorization requirements, copays, deductibles, and other out-of-pocket costs are determined by my insurance plan. Medication availability and pharmacy fulfillment are not guaranteed by Valēre Wellness Group. • I understand some medications may require prior authorization and that submission of a prior authorization does not guarantee insurance approval. • I understand labs, vitals, outside records, or additional follow-up may be required before treatment is recommended or continued.
I have read, understood, and agree with the above statements.
48
Care Pathway and Pricing Information

Most patients are appropriate for asynchronous care following clinical review.

Most intake reviews are completed within 24–48 business hours. More complex cases or requests requiring additional information may require additional review time.

However, some patients may require a synchronous video consultation prior to treatment recommendations or prescribing, depending on medical complexity, safety considerations, or clinical appropriateness.

Patients who do not complete recommended follow-up evaluation may not be eligible to proceed with treatment recommendations, prescribing, or ongoing care.

The initial assessment fee is applied toward the cost of the video consultation if additional synchronous evaluation is required.

Total cost for patients requiring video evaluation is $179. If synchronous video evaluation is required, the remaining balance due after the initial assessment fee is $50.

Submission of this intake does not guarantee medication eligibility, prescribing, or asynchronous treatment appropriateness.
49

Thank you for your interest.

If you have any questions, please contact us at hello@valerewellnessgroup.com
50
Urgent Medical Evaluation Recommended

Based on your responses, this service may not be appropriate for your current medical needs.

Please seek urgent medical evaluation or contact emergency services if needed.

If you may harm yourself or someone else, call 988 or seek emergency care now.
51
California Residency Required

At this time, care is only available to patients physically located in California during evaluation and treatment.

Thank you for your interest.

You may now exit the form. If you have any questions, please contact us at hello@valerewellnessgroup.com
52
Age Requirement

This service is currently available only to adults age 18 and older.

Thank you for your interest.

You may now exit the form. If you have any questions, please contact us at hello@valerewellnessgroup.com
53
Video Trigger Flag
54
Video Preference Flag
55
Complexity Score
56
Metabolic Severity Score
57
Medication Limitation Flag
58
Clinician Review Flag
59
BMI value
60
Payment and Intake Submission* This field is required.Your intake assessment will be reviewed after payment and submission are completed. Payment does not guarantee medication eligibility, prescribing, asynchronous treatment appropriateness, or finalized treatment recommendations. Your payment covers the Valēre Wellness Group intake assessment only and does not include medication, laboratory, pharmacy, or other outside-service costs. Additional synchronous evaluation, laboratory testing, medical records, or follow-up may be required based on clinical review and patient safety considerations. Most intake reviews are completed within 24–48 business hours, though more complex cases or requests for additional information may require additional time.
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