Multi-System Health Assessment Intake Form
Complete this intake form to provide a comprehensive overview of your current health across multiple body systems.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
How would you rate your overall health in the past month?
*
1
2
3
4
5
Which of the following symptoms have you experienced recently? (Select all that apply)
Fatigue
Headache
Digestive discomfort
Muscle or joint pain
Shortness of breath
Skin changes
Sleep disturbances
Other
In the past two weeks, how often have you felt anxious or stressed?
*
Never
Rarely
Sometimes
Often
Almost always
Please indicate your current level of physical activity.
Sedentary (little or no exercise)
Lightly active (light exercise/sports 1-3 days/week)
Moderately active (moderate exercise/sports 3-5 days/week)
Very active (hard exercise/sports 6-7 days/week)
Other
Review of Systems
Rows
Never
Rarely
Sometimes
Often
Respiratory (e.g., cough, wheezing)
1
2
3
4
Cardiovascular (e.g., palpitations, chest discomfort)
5
6
7
8
Digestive (e.g., nausea, bloating)
9
10
11
12
Musculoskeletal (e.g., aches, stiffness)
13
14
15
16
Neurological (e.g., dizziness, tingling)
17
18
19
20
Do you have any known allergies?
No
Yes (please specify below)
Please list any current medications or supplements you are taking.
Is there anything else you would like to share about your health or wellness goals?
Submit
Should be Empty: