Wellness Simplified New Patient Intake  ·  wellnessimplified.com
Physician-Aligned Wellness Protocols

New Patient
Intake Form

All information is strictly confidential and used solely to build your personalized recovery protocol. Please complete each section as thoroughly as possible.

Personal Procedure Medical Lifestyle Blood Work Review
01

Personal Information

Your basic details and how to reach you

Step 1 of 6
02

Procedure & Goals

Tell us about your upcoming procedure and what you hope to achieve

Primary Wellness Goals — select all that apply
Step 2 of 6
03

Medical History

Current medications, supplements, and known conditions

Diagnosed Conditions — select all that apply
Step 3 of 6
04

Lifestyle & Habits

Help us understand your current daily patterns

Current Stress Level
Very lowVery high
Current Energy Level
ExhaustedExcellent
Step 4 of 6
05

Blood Work & Lab Values

Enter your values if you have recent results — leave blank if unavailable

Metabolic Panel
Fasting Glucosemg/dL
HbA1c%
Fasting InsulinμIU/mL
Total Cholesterolmg/dL
LDLmg/dL
HDLmg/dL
Triglyceridesmg/dL
Hormones
TSHmIU/L
Free T3pg/mL
Free T4ng/dL
Estradiol (E2)pg/mL
Progesteroneng/mL
Testosterone (total)ng/dL
DHEA-Sμg/dL
Cortisol (AM)μg/dL
Nutrients & Vitamins
Vitamin D (25-OH)ng/mL
Vitamin B12pg/mL
Folateng/mL
Iron (serum)μg/dL
Ferritinng/mL
Magnesium (RBC)mg/dL
Zincμg/dL
Inflammation & Other
hs-CRPmg/L
Homocysteineμmol/L
IGF-1ng/mL
ALTU/L
ASTU/L
eGFRmL/min
Lab Date
Step 5 of 6
06

Review & Submit

Final notes and consent before we build your protocol

By submitting this form, I confirm that all information provided is accurate and complete to the best of my knowledge. I understand that Wellness Simplified provides wellness and recovery guidance and does not replace medical care from a licensed physician. I consent to my information being used to create a personalized wellness protocol, and I agree to be contacted by the Wellness Simplified team.

Step 6 of 6

Your intake is complete.

Thank you for trusting us with your wellness journey. Your dedicated coordinator will review your intake and have your personalised protocol ready within 48 hours.

We will reach out to you shortly.

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