📝 New Patient Consultation Intake Form

📝 New Patient Consultation Intake Form
Welcome to Bottumzup Health and Wellness!

To help us prepare for your consultation, please complete the following form prior to your visit.

This form helps me understand your health history, concerns, and goals before your first visit so I can provide safe, personalized, and effective care from the start.

Please complete all sections. If something doesn’t apply, write “N/A” or none of the above.

🔒 Your information is private and protected under HIPAA. It will only be used for your care and kept confidential.
Name*

First NameLast Name
DATE OF BIRTH*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY CONTACT NAME*
RELATIONSHIP*
EMERGENCY CONTACT PHONE*
REASON FOR VISIT*
If you have any recent lab results, please email them to
bottumzuphealthandewellness@gmail.com so they can be reviewed prior to your visit.
HAVE YOU HAD LABS DONE WITHIN THE LAST YEAR? IF SO WHEN*
DO YOU HAVE ANY MEDICAL CONDITIONS*

YESNO
CARDIOVASCULAR AND RESPIRATORY --Please check any conditions that apply to you:*

HIGH BLOOD PRESSURECARDIAC SURGERY OR STENTSPERIPHERAL ARTERY DISEASECOPDSHORNTESS OF BREATHLUNG CANCERHEART MURMURHEART ATTACKCONGESTIVE HEART FAILUREASTHMAHISTORY OF DVT OR PULMONARY EMBOLISMNONE OF THE ABOVE
IF YES, PLEASE LIST
GASTROINTESTINAL AND URINARY*

ACID REFLUXBLADDER DISEASEKIDNEY DISEASELIVER DISEASEHEPATITIS A, B, CCONSTIPATIONIBSCROHNS DISEASEGASTRIC BYPASSHISTORY OF PANCREATITISNONE OF THE ABOVE
IF YES, PLEASE LIST
METABOLIC/ENDOCRINE/AUTOIMMUNE*

HYPERTHYROIDISMHYPOTHYROIDISMTYPE 1 DIMTYPE II DMRHEUMATOID ARTHRITISNONE OF THE ABOVE
IF YES, PLEASE LIST
HISTORY OF MEDULLARY THYROID CANCER? YOURSELF OR FAMILY*

YESNO
IF YES WHO?
NEURLOGIC*

STROKEMULTIPLE SCLEROSISPARKINSONSSEIZURESALZHEIMERSCHRONIC MIGRAINESNONE OF THE ABOVE
IF YES, PLEASE LIST
HEMATOLOGY*

ANEMIAGPD6 DEFICIENCYHISTORY OF BLOOD TRANSFUSIONMTHFR GENENONE OF THE ABOVE
IF YES, PLEASE LIST
MUSCULOSKELETAL*

CHRONIC BACK PAINCARPAL TUNNEL SYNDROMEFIBROMYALGIADEGENERATIVE JOINT DISEASENONE OF THE ABOVE
IF YES, PLEASE LIST
PSYCHOLOGICAL*

DEPRESSIONANXIETY OR PANIC ATTACKSSLEEP DISTRUBANCES (INSOMNIA, NARCOLEPSY)DIFFICULTY CONCENTRATING OR MEMORY ISSUESSUICIDAL THOUGHTS OR IDEATIONMOOD SWINGSHISTORY OF SELF HARMNONE OF THE ABOVE
IF YES, PLEASE LIST
LAST MENSTRUAL PERIOD--WOMEN ONLY- NON MENOPAUSAL (MEN PLEASE WRITE N/A)*
WOMEN ONLY DO YOU HAVE HISTORY OF...*

PCOSFIBROMYALGIAENDOMETRIOSISPERIMENOPAUSEMENOPAUSEIRREGULAR MENSTRUALNONE OF THE ABOVEDOES NOT APPLY
If a questions below do not apply to you, please write "N/A" in the space provided
DO YOU HAVE ANY DRUG OR FOOD ALLERGIES? *
PAST SURGERIES OR HOSPITALIZATIONS*
CURRENT MEDICATIONS OR SUPPLEMENTS*
IF YES, PLEASE LIST
DO YOU HAVE A SPECIFIC DIET? (EX: GLUTEN, KETO, INT FASTING, CARDIAC, RENAL)*

YESNO
IF YES PLEASE LIST
SLEEP HOURS*

<44-66-8>8
EXERCISE REGULARLY*

YESNO
IF YES WHAT TYPE AND HOW OFTEN?
STRESS LEVEL*

LOWMODERATEHIGH
DO YOU USE ANY OF THE FOLLOWING*

TOBACCOVAPINGMARIJUANA (SMOKED OR VAPED)MARIJUANA (EDIBLES OR OTHER FORMS)NO, I DO NOT CURRENLTY USE ANY OF THE ABOVEI QUIT
IF YOU SMOKE? HOW MUCH AND FOR HOW MANY YEARS?, IF QUIT WHEN DIID YOU STOP?*
DO YOU DRINK ALCOHOL?

NEVEROCCASIONALLY (LESS THAN ONCE A WEEK)SOCIALLY (1-2X PER WEEK)REGULARLY (3-5X PER WEEK)DAILY OR ALMOST DAILYPREFER NOT TO SAY
IF YES HOW OFTEN AND HOW MUCH?
DO YOU HAVE PRIMARY CARE PROVIDER, IF SO NAME
WOULD YOU LIKE TO TELL US ANYTHING ELSE THAT YOU FEEL IS IMPORTANT?
☑️ Self-pay patients: Please be aware of consultation fees, which may include lab ordering, review, and treatment planning. Fees will be discussed at or before your visit.
TELEMEDICINE VISIT
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TELEMEDICINE CONSULTA $50 consultation fee is required to schedule your initial telemedicine appointment. This fee covers your provider’s time, medical review, and personalized recommendations during the virtual visit. Please note: The consultation fee is non-refundable, regardless of whether you choose to proceed with further care or services. Payment is required at the time of booking to confirm your appointment. You will be redirected to PayPal to securely complete your payment. If follow-up visits are needed, standard telemedicine visit fees will apply.
$50.00 Quantity

Total

$0.00
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If you would like to complete your payment using another payment link, please text us at 407-993-1491 and we will provide you with a link for payment.
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