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Intake Form

Please fill out this intake form as thoroughly as you can. This will help guide our initial recommendations for testing, nutrition, exercise and lifestyle.

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Question 1 of 34

First and Last Name

Question 2 of 34

DOB

Question 3 of 34

Home Address

Question 4 of 34

Phone Number

Question 5 of 34

What weekdays/times work best for your appointments with your provider? (Please include timezone)

Question 6 of 34

What is the current status of your menstrual cycles?

A

None

B

Irregular

C

Regular

Question 7 of 34

 What was the first day of your last menses?

Question 8 of 34

Have you had your ovaries removed?

 

A

Yes - 1

B

Yes - 2

C

No

Question 9 of 34

Are you currently pregnant?

A

Yes

B

No

Question 10 of 34

Please select which one applies to you:

A

I am NOT in menopause

B

I am in perimenopause

C

I am in menopause

D

I am post menopausal

E

I'm not sure, but I think I may be in perimenopause

Question 11 of 34

Are you currently taking a birth control?

If yes, what type, how long have you been taking it and what was the purpose for starting it?

 

Question 12 of 34

Please list all medications and supplements you are currently taking.

Question 13 of 34

Please list your history of vaccines.

Question 14 of 34

Please list your history of major illnesses: (mono, strep throat etc).

Question 15 of 34

Please list your history of major injuries.

Question 16 of 34

When is your fatigue the worst and rate it on a scale of 1-10.

(Select all that apply)
A

My fatigue is worst in the morning

B

My fatigue is worst in the afternoon

C

My fatigue is worst in the evening

D

I am not struggling with fatigue

E

It's a 1-3

F

It's a 4-6

G

It's a 7-9

H

It's a 10

Question 17 of 34

 Are you taking any of the following? 

 

(Select all that apply)
A

DIM/I-3-C

B

Thyroid (T3, T4)

C

Hydrocortisone Cream

D

Steroid Inhaler or nasal spray

E

Creatine

F

Glucocorticoid (prednisone, dexamethasone, etc)

G

Diabetes medications

H

Opoids (narcotic) pain medications (hydrocodone, fentanyl, codeine, oxycodone, etc)

I

Blood Pressure Medications

J

5-HTP

K

Antidepressants/SSRIs

L

Estrogen

M

Progesterone

N

Testosterone

O

Pregnenolone

P

Melatonin

Q

Cortisol

R

None

Question 18 of 34

Which of the following do you suspect you have or have you been diagnosed with?

(Select all that apply)
A

Addison’s Disease

B

Adrenal Insufficiency

C

Chronic Fatigue

D

Cushing’s Disease

E

High Blood Pressure

F

Hyperthyroid (overactive)

G

Hypothyroid (underactive)

H

Kidney Disease

I

Type 2 Diabetes

J

PCOS

K

None

Question 19 of 34

What are the main hormone related challenges you are currently experiencing?

(Select all that apply)
A

Hair Issues (loss of scalp hair, slow growth, increased body/facial hair)

B

Skin Concerns (dry skin, acne, etc)

C

Low libido or changes in sexual drive

D

Mood swings, irritability, or anxiety

E

Irregular menstrual cycles

F

Painful or heavy periods

G

Uterine Fibroids

H

Hot flashes or night sweats

I

Vaginal Dryness

J

Persistent fatigue or low-energy

K

Difficulty losing weight or unexplained weight gain

L

Sleep issues (difficulty falling asleep, staying asleep, or waking up unrefreshed)

M

Brain fog or difficulty focusing

N

Digestive issues (bloating, constipation, etc.)

O

Frequent headaches or migraines

P

None

Question 20 of 34

What have you already tried to address these issues?

(Select all that apply)
A

Traditional medicine (e.g., hormonal birth control, thyroid medication, etc.)

B

Over-the-counter supplements or herbs

C

Specific diets (e.g., keto, paleo, intermittent fasting, etc.)

D

Exercise programs or personal training

E

Holistic or alternative therapies (e.g., acupuncture, chiropractic care, etc.)

F

Hormone replacement therapy (HRT)

G

Stress management practices (e.g., meditation, yoga, etc.)

H

Lifestyle changes (e.g., sleep hygiene, reducing toxins, etc.)

I

None of the above

Question 21 of 34

How long have you been dealing with these symptoms?

A

Less than 6 months

B

6 months to 1 year

C

1-2 years

D

3+ years

Question 22 of 34

What are your biggest health goals right now?

(Select all that apply)
A

Restoring energy and vitality

B

Achieving sustainable weight loss

C

Regulating my menstrual cycle

D

Optimizing fertility

E

Stabilizing my mood and emotions

F

Improving libido and sexual health

G

Sleeping better and waking up refreshed

H

Feeling in control of my body and health

I

Healing naturally without dependence on medications

Question 23 of 34

How do these symptoms affect your daily life?

(Select all that apply)
A

I feel constantly exhausted

B

I struggle to keep up with my kids/family

C

My relationships are impacted due to mood swings or low libido

D

I don’t feel like myself anymore

E

I’ve lost confidence in my body and health

F

My work or productivity is suffering due to fatigue or brain fog

Question 24 of 34

What are you struggling with most right now?

Question 25 of 34

How many hours of sleep per night are you getting?

Question 26 of 34

How many bowel movements do you have per day? What is the consistency of them (soft or hard)? Do you have pain with the bowel movements or are they hard to pass? Any strange color or odor to the bowel movements? Any blood in the stool? 

Question 27 of 34

Do you experience bloating? When? Can you point to any triggers? Are you noticeably distended? 

Question 28 of 34

Do you experience acid reflux or nausea? 

Question 29 of 34

How would you rate your current nutrition? What does a typical day of eating look like?

Question 30 of 34

How would you rate your current movement? What types and how much are you doing each week?

Question 31 of 34

What are your top 3-5 goals for the next 6 months within this program?

Question 32 of 34

When it comes to your care, we want to make sure we are communicating effectively. Which statement best describes you?

A

Just tell me what to do.
I prefer simple, clear instructions and don't need a lot of background information.

B

Give me the basics and the reasons why.
I like straightforward recommendations, but I also want a brief explanation of why they're important.

C

I want to dive into the details.
I enjoy thorough explanations and like learning about the science, reasoning, and processes behind my care.

Question 33 of 34

Is there anything else you feel I should know?

Question 34 of 34

How did you hear about us?

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