Complete Your Health Intake Form

Thank you for scheduling your consultation. Please complete the form below before your appointment so we can review your health history in advance.

Personal Information

First Name *

Last Name *

Email *

Phone *

City *

Country *

State *

Postal Code *

Date Of Birth *

Biological Sex *

Height (ft/in) *

Weight (lbs) *

Occupation *

Health Goals & Current Concerns

What is your primary goal? *

What symptoms are you currently experiencing? *

How long have you been experiencing these symptoms? *

What prompted you to seek blood work or a blood work consultation? *

Are there any specific health concerns or biomarkers you would like us to focus on? *

What does a successful outcome from working with us look like? *

Medical History, Medications, Supplements & Hormones

Do you have any diagnosed medical conditions? *

Are you currently taking any medications? *

What supplements are you currently taking? *

Have you had any significant surgeries or medical procedures? *

Do you have any known allergies? *

Do you have any relevant family history of medical conditions? *

Are you currently receiving TRT, HRT, or other hormone therapy? *

Please describe your current hormone therapy *

Previous Blood Work & Lab Upload

Have you had blood work performed within the past 12 months? *

When was your most recent blood work performed? *

Upload your most recent blood work

PDF

Nutrition & Lifestyle

Describe your current eating habits. *

Do you follow any specific diet or eating style? *

Do you have any food allergies or intolerances? *

How much water do you typically drink per day? *

How often do you consume alcohol? *

How much caffeine do you typically consume per day? *

Activity, Sleep, Stress & Recovery

How active is your typical workday? *

What is your average daily step count? *

How many hours of sleep do you average per night? *

How would you rate your sleep quality? *

Do you generally wake up feeling rested? *

Do you have difficulty falling asleep or staying asleep? *

How would you rate your average stress level? *

What are your primary sources of stress? *

What do you currently do to manage stress and recover? *

How would you rate your energy throughout the day? *

How would you rate your overall recovery? *

Final Information

Are there any current health symptoms or concerns we should be aware of? *

Is there anything else you would like us to know before reviewing your blood work? *

Consent & Agreement

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from Optimal Vitality Services at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

OVS Coaching Consent & Acknowledgment *

I acknowledge that the coaching, training, nutrition, lifestyle, and wellness information provided by Optimal Vitality Services is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any disease or medical condition. I understand that these services are not a substitute for medical care, diagnosis, or treatment from a qualified healthcare professional. I confirm that the information I provide is accurate to the best of my knowledge and agree to inform Optimal Vitality Services of any relevant changes to my health, medications, injuries, symptoms, or physical limitations. I understand that participation in exercise and lifestyle changes involves inherent risks and accept responsibility for my participation.