WELLNESS 360 INTAKE WELLNESS 360 INTAKE Welcome! Thank you for choosing SIMPLY DAWN. Please complete this 10-minute intake to help us focus on you - not your paperwork - during your upcoming appointment. Your answers will help us understand your primary health concerns and health history. We will use this information (along with other tools) to help address the root causes of your symptoms and health concerns, and create a personalized plan for you. We look forward to assisting you in establishing a foundation for long-term health and vitality. Your information is stored in HIPAA-compliant systems and is viewed only by our SIMPLY DAWN team and the accredited facilities that may process any relevant lab tests. Thank you for helping us set you up for success! BASIC INFORMATION Name * Name First First Last Last Birth Gender * Male Female Birthday (M/D/Y) * Email * Mobile Phone * Address * Address Address Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Emergency Contact Name * Emergency Contact Name First First Last Last Emergency Contact Mobile Phone * Occupation Religious Affiliation (if applicable for nutrition purposes) How did you hear about us? * Select OneFriendFamily MemberWebsiteInstagramFacebookEmail If you were referred, please share the name of the person who referred you: Marital Status Select OneSingleMarriedPartneredDivorcedWidowed What are your primary concerns? How long have you been struggling with these issues? On a scale of 1-10, how much is your quality of life being affected? 1 2 3 4 5 6 7 8 9 10 What professional/s have you seen for these issues? Are you currently under a doctor's care? Yes No If yes, please provide the doctor's name & practice phone number: Have you had testing and/or lab work done? Yes No If yes, what testing and how long ago? What diagnosis or results were found? Have you undergone treatment/s or tried any therapies to help resolve your issues? If so, what? Are you on a special diet? Yes No If yes, what type of diet? Was this diet prescribed by a medical doctor? Yes No N/A If yes, what is the prescribing doctor's name & practice phone number? On average, what is your current stress level? 1 2 3 4 5 6 7 8 9 10 List the main sources of stress in your life: Are you currently pregnant or nursing? Yes No N/A HEALTH HISTORY Height Weight MEDICATIONS / SUPPLEMENTS: Please list any prescription or OTC medicines & supplements you currently take, including dosages and how long you have been taking each: Have you used antibiotics frequently over time or taken long-term antibiotics? Yes No Have you used hormonal contraceptives for 2+ years? Yes No N/A If yes, what type of contraceptive/s and how long? Please list all known allergies and/or food sensitivities: Please list any significant illnesses or heredity-related conditions in your family tree, and who has had them: Please list any health conditions you are currently experiencing or have been diagnosed with, and how long you have had each one: Do you have a history of chronic stress or fatigue? Yes No Please list all hospitalizations, surgeries, or major injuries you have had, how long ago, and whether the condition was resolved: Have you been treated for cancer? Yes No If yes, what type & how long ago? Do you have a thyroid abnormality or condition that has not already been disclosed? Yes No If yes, what type? Do you have any type of auto-immune disorder that has not already been disclosed? Yes No If yes, what type? Were you immunized as a child? Yes No If yes, did you have any negative reactions? If so, please describe: Do you participate in vigorous aerobic activity or sports? Yes No If yes, what type & how often? Do you smoke or use tobacco? Yes No If yes, how much & how often? Do you drink alcohol? Yes No If yes, how much & how often? Please share any other information or insights that have not been covered that may be helpful in addressing root causes of your current health status: By signing this form, I am acknowledging that I have completed this information to the best of my knowledge, and I have been candid in disclosing the information requested. I understand that this information will be used in conjunction with other tools and applicable lab tests to determine the best course of action for improving my overall health, body function, and quality of life. I also understand that this information will be used to determine which products and ingredients may safely be recommended to me. I understand that 1) before and after photos may be taken to document treatment processes and/or results, 2) these photos may be used by SIMPLY DAWN for business and/or marketing purposes, and 3) I may request to have my identity masked prior to posting publicly. I am either of lawful age and I am signing for myself, or I am a legal parent/guardian and I give my consent for my minor to proceed. SIGNATURE * signature keyboard Clear PARENT/GUARDIAN SIGNATURE (if client is a minor) signature keyboard Clear Date Submit If you are human, leave this field blank. Δ
