Client Intake Form

01

Personal Information

Full Name

Date of Birth

Email Address

Phone Number

Format: (555) 123-4567

Address

City

State

Zip

Emergency Contact (Name & Phone)

02

Physical Metrics

Height

Current Weight (lbs)

Goal Weight (lbs)

03

Medical History

04

Medications, Supplements & Peptides

Current prescription medications (include dosage if known)

Current supplements (vitamins, herbal, OTC)

Previous or current peptide use (type and duration)

05

Lifestyle

Exercise days per week

Type of exercise

Average hours of sleep / night

Daily water intake (approx.)

Alcohol use

Tobacco use

06

Primary Goals

07

Symptom Checklist (optional)

08

Priority Health Goals

List your top three health goals in order of importance.

Goal #1 (most important)

Goal #2

Goal #3

09

Biggest Health Challenge

What has been your biggest obstacle or frustration in achieving your health goals?

10

Previous Health Efforts

11

Commitment Level

12

Stress Level

How would you rate your current stress level?

LowModerateHighSevere

13

Daily Energy

14

Digestive Health

15

Hormone History

For Male Clients

Have you ever had testosterone levels tested?

YesNo

If yes, results if known

For Female Clients

Are you currently pregnant or trying to become pregnant?

YesNo

16

Vision of Success

If we are successful together, what would your life look like 12 months from now?

17

Additional Information

Anything else you'd like us to know about your health or goals?

18

Acknowledgment, Consent & Electronic Signature

Peptides discussed are investigational research compounds and are not FDA-approved for the diagnosis, treatment, prevention, or cure of any disease. Information and guidance provided are for educational and wellness consultation purposes only and do not constitute medical advice, diagnosis, or treatment. Participation is voluntary. Always consult a qualified licensed healthcare provider regarding medical concerns, existing conditions, or prescription medications before beginning any new wellness protocol. This practice is not a HIPAA-covered entity; reasonable measures are taken to safeguard your information, but it is not protected under HIPAA.

I have read, understand, and voluntarily agree to the Sanctum Vitalis Disclaimer, Terms & Privacy Policy and the informed consent language above. I confirm the information I have provided is accurate and complete to the best of my knowledge.

Electronic Signature — Type your full legal name

Typing your name here serves as your electronic signature under the E-SIGN Act and is legally binding. It must match the Full Name you entered in Section 01.

Submission date & time will be recorded automatically and stored with this intake.

Confidential intake. The first step.