Pre-Consultation Intake and Screening Package

Section 1: Basic Information

Full Name * Date of Birth * Phone Number * Email Address * State of Residence * Preferred Contact Method *

Section 2: Goals & Reason for Inquiry

Tell us what brought you here and what success looks like to you.

Fatigue / low energy Hormone optimization Weight loss / body composition Muscle / performance Sexual health Longevity / prevention Focus / cognition Peptides / recovery

Other goal In your own words, what are your top 3 goals? * If we fast forward 3 to 6 months, what would success look like? *

Section 3: Health Background

Are you currently under the care of another provider for hormones, peptides, or weight loss treatment? * Please list current medications, hormones, peptides, and supplements. *

Have you ever been diagnosed with any of the following?

Other medical conditions or safety concerns

History of hormone-sensitive cancer? * For women: pregnant, breastfeeding, or planning pregnancy?

Section 4: Prior Treatment Experience

Testosterone therapy Estrogen / progesterone therapy Peptides GLP-1 or weight loss medication Thyroid medication None

If you have used any prior treatment, what helped and what did not?

Section 5: Compliance & Care Expectations

Initial each statement to confirm agreement.

I understand Human Performance is a physician-led, cash-pay telehealth practice. I understand treatment is based on provider evaluation, symptoms, labs, and medical necessity. I am willing to complete labs and follow-up visits when clinically required. I understand medications and refills cannot be provided outside proper visits and review. I agree to communicate through official clinic channels, not a provider’s personal number. I understand submitting this packet does not guarantee that treatment or prescriptions will be offered.

Section 6: Financial Readiness

Initial each statement to confirm agreement.

I understand the initial consultation fee is $300. I understand follow-up care may require membership or per-visit fees. I understand medications, labs, and add-ons may carry separate costs unless otherwise included. I confirm I am financially prepared to proceed with this model of care. I understand that if I cancel with less than 24 hours’ notice, I will be charged a late cancellation fee of $50. I understand that if I do not show up and do not contact Human Performance, I will forfeit my prior payment, be charged an additional $50, and will have to pay for another appointment.

Section 7: Alignment Check

Check all that apply.

I want a provider-guided plan based on symptoms, diagnostics, and long-term care. I am primarily seeking a specific medication, refill, or protocol. I am open to education, lab review, and a customized treatment plan if appropriate.

Anything else you want the provider or staff to know?

Section 8: Consent & Attestation

Initial each statement and sign below.

I certify that the information I provided is truthful and complete to the best of my knowledge. I understand that Human Performance may decline to establish care if I am not an appropriate fit. I understand all care is provided via telehealth and remains subject to provider discretion and medical necessity.

Patient Signature / Full Legal Name * Date * Printed Name * Staff Review

Important: This packaged version can submit through FormSubmit for testing. For real patient PHI, connect this form to Optimantra, Jotform HIPAA, Formstack HIPAA, IntakeQ, or another HIPAA-secure backend with a signed BAA.

Pre-Consultation Intake