Follow the steps to successfully complete the intake form.

1. Press the ‘Get Form’ button to access the intake form and open it in your preferred browser.
2. Fill in your patient information, starting with your full name, date, and date of birth in the specified format (MM/DD/YY). Ensure the details entered are accurate and match your official documents.
3. Indicate your gender by selecting the appropriate option. Provide your full address and phone numbers for home, work, and mobile contacts. Also, include your email address.
4. Respond to the question regarding phone messages by marking 'Y' for yes or 'N' for no on whether you would like the clinic to leave messages.
5. Include an emergency contact's name, their phone number, and your relationship to that person.
6. Identify who referred you to the clinic, if applicable, and list their name.
7. In the medical history section, list your health goals in order of importance as requested. Be sure to capture concerns along with the dates since they started.
8. Describe any changes or worsening of health issues over time, as well as their effects on your daily life.
9. Evaluate your general state of health by selecting one of the options provided: excellent, good, fair, or poor.
10. In the medications/supplements section, list all current medications and supplements, including prescription drugs, along with their purpose, start date, and dosage/frequency.
11. Answer the questions regarding the use of antibiotics in the last five years, listing the most recent course taken.
12. Indicate any substances you use or have used, including tobacco, alcohol, recreational drugs, and others, while providing details on the amount and frequency.
13. In the allergies section, document any known or suspected allergies, sensitivities, or intolerances across the specified categories.
14. For family history, indicate whether immediate family members have a history of any specified conditions.
15. Provide your current weight alongside desired and maximum weights, including the dates for these maximum and minimum weights.
16. Mention any significant weight changes in the past 6-12 months along with the amount of change.
17. List any food allergies or intolerances, dietary restrictions, and provide a typical day’s diet breakdown including meals and beverages.
18. Discuss your lifestyle, sharing details about your occupation, stress levels, exercise habits, and other relevant lifestyle factors.
19. Provide any additional information you feel is important that was not covered in the previous sections.
20. Once you have completed the form, review your entries for accuracy and clarity. Save changes, download, print, or share the form as needed.

Begin completing your intake form online today to ensure your health needs are met!