Health Intake Form Health Intake Form Last nam(Required) First name* Last name* Date of Birth MM slash DD slash YYYY Sex*(Required)SelectMaleFemaleEmail*(Required) Shipping address: Street City State SelectAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip Health Information: HeightFeet Inches Current Weight (lb) Desired Weight (lb) Exercise FrequencySelectDailyFew Times / WeekWeeklyRarelyNeverMedical History : Please check all that apply Hypertension (high blood pressure) Heart Disease (coronary artery disease, heart attack, heart failure, arrhythmia, valvular disease / replacement ...) Hyperlipidemia (high cholesterol) Diabetes (Type I or Type II, insulin or oral medications) History of Stroke or TIA (transient ischemic attack) Gastrointestinal disease (colitis, chronic constipation, Crohn’s Disease, diverticulitis, irritable bowel syndrome, gastroesophageal reflux, hiatal hernia, gastric ulcer) Kidney disease (with or without dialysis) Pulmonary disease (COPD, emphysema, asthma) Liver disease (hepatitis, cirrhosis, gallbladder disease ) History of Bariatric Surgery Endocrine Disorder (thyroid or parathyroid disease) Ovarian / Breast / Uterine: (menopause, amenorrhea, fibrocystic breast disease, hysterectomy, uterine fibroma) Prostate Problems Neuropsychiatric: (anxiety, depression, Alzheimer’s, bipolar disorder, seizure disorder, Parkinson’s, Schizophrenia) inflammatory Conditions: (e.g. Lupus, Rheumatoid arthritis, Polymyalgia, Psoriasis) Malignancy / Cancer Weight Gain / Weight Changes Overweight / Obesity Memory Changes / Poor Memory Sexual Dysfunction / Low Libido Cancer: specify type(s): Please provide details for any conditions checked above or others not listed above:Home Medications: check all that apply ACE-Inhibitor (e.g. Lisinopril, Captopril, Benazepril, others) ARB (Losartan, Valsartan, Olmesartan, Entresto, others) Calcium Blocker (Amlodipine, Nifedipine, Verapamil, others) Beta-Blocker (Carvedilol, Atenolol, Metoprolol, Bisoprolol, others) Vasodilator (Hydralazine, others) Statin for Cholesterol (Rosuvastatin, Atorvastatin, Pravastatin, Simvastatin, others) Non-Statins for Cholesterol (Nexletol, Zetia, Praluent, Repatha) Insulin for diabetes Non-insulin diabetes meds (Metformin, Glyburide, , Jardiance, Farxiga, Wegovy, others) Thyroid Medication (Synthroid, NP Thyroid, others) Diuretic (Furosemide / Lasix, Hydrochlorothiazide, Spironolactone, Aldactone, Bumetanide, Torsemide, others) Anxiety / Depression / Anxiety meds Sleeping Meds (Ambien, Benadryl, Trazodone, Melaton in, others ) Hormone Replacement / Birth Control Sexual function: (Sildenafil / Viagra, Cialis / Tadalafil , others) GI Meds: (Pepcid, Protonix, Nexium, Tagamet, others) Weight Loss Meds: (Phentermine, Jardiance, Mounjaro, Wegovy, others) None of these Please Specify: Other Medications: Please list:Medication Allergies: Please list:Food Allergies: Please list:Health Areas Important to You: Cardiovascular Digestive Respiratory Improved Memory Athletic Performance Pain Relief Sexual Health Exercise Optimization / Increased Energy Vegan Weight Loss *We do not sell or share your data with third parties other than for the sole purpose of analyzing and producing your tailored health profile.
