Optimal Wellness Intake - Cobb Wellness and Aesthetics

Name: *

What is your date of birth? Month-Day-Year

Email *

What is your sex?

Phone

What would you like to improve?

Please tell us more about your main concerns and what has been bothering you most

Are you taking hormone replacement (sex hormones and/or thyroid hormone replacement?

If yes, what are you taking?

What medications are you taking?

What supplements are you taking?

Do you have any medical condition or concerns what we should know about?

Have you ever been diagnosed with cancer?

If yes, what kind of cancer and what was your trearment?

If you are a female, when was your last mammogram?

If you are a male, when was your last PSA and/or prostate exam?

Do you experience anxiety or depression?

If so, are you on a treatment plan?

How often do you consume alcohol?

How often do you exercise in a week?

What type of exercise do you do?

Do you wake up feeling rested and restored?

Do you feel stressed?

What kind of stresses are you dealing with?

Do you have an injury or aches in your joints?

Is it easy for you to recover from a workout?

If not, how long does it take you to recover?

Do you have any gut issues like bloating, constipation or loose stool?

Do you experience brain fog?

Please let us know about anything you think it is important for us to know that has not been addressed in this form.