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New Patient Intake Form

  1. Patient Demographics

Birthday
Month
Day
Year
Height - Feet
Height - Inches
Multi-line address
Preferred Contact method
Call
Text
Email

  1. Personal Medical History

Metabolic & Cardiovascular (check all that apply)
Endocrine & Hormonal (check all that apply)
Respiratory & Sleep (check all that apply)
Gastrointestinal/Liver/Renal (check all that apply)
Neurologic & Mental Health (check all that apply)
Autoimmune/Cancer (check all that apply)

  1. Allergies

  1. Current Medications & Supplements

  1. Healthcare Providers

Are you currently under the care of a Primary Care Physician?
I am currently under the care of a doctor/provider
I am not currently under the care of a doctor/provider

  1. Lifestyle

Physical Activity
Rare
1 - 2 Days/Week
3 - 4 Days/Week
5+ Days/Week
Diet & Nutrition (self-rating)
Good / Healthy
Fair / Inconsistent
Poor
Tobacco/Nicotine/Vaping
Never
Former
Current User
Other
Alcohol Use (drinks per week)
None
1 - 3 Drinks/Week
4 - 7 Drinks/Week
8+ Drinks/Week

  1. Immediate Family Member Health History (parents, siblings, children)

  1. Consent & Signature

I certify that the information provided is accurate to the best of my knowledge. I understand this form assists T2YourHealth in supporting my wellness and metabolic health and will be kept confidential.

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