Intake Form — CoreBalance Health

Personal information

First name *

Last name *

Date of birth *

Biological sex *

Phone number *

Email address *

Street address

Preferred contact method

Best time to reach you

Emergency contact — name & phone

Reason for visit

What brings you to CoreBalance Health? Select all that apply *

GLP-1 therapy — weight management & metabolic health (Semaglutide, Tirzepatide) Peptide therapy Hormone therapy — testosterone, estrogen, progesterone, or thyroid optimization General wellness & preventive care Lab review or follow-up care Other

Describe your primary concern or goal

Surgical history

Have you had any surgeries or major procedures?

Please list surgeries and approximate year

Have you previously tried GLP-1 medications (Ozempic, Wegovy, Mounjaro, Zepbound, etc.)?

Which medication(s), dose(s), and how did you respond?

Have you received hormone or peptide therapy before?

Type of therapy, provider, dates, and results

Personal cancer history

This information helps us determine the safest and most appropriate therapy options for you, particularly regarding hormone-sensitive therapies.

Have you ever been diagnosed with cancer?

Type of cancer Year of diagnosis Treatment received Current status

Have you had any precancerous conditions (dysplasia, polyps, LCIS, DCIS, Barrett's esophagus, etc.)?

Type, year, and any treatment

Family cancer history

Do any immediate family members (parents, siblings, children) have a history of cancer?

Family member, cancer type, and approximate age at diagnosis

Any known genetic mutations (BRCA1/2, Lynch syndrome, PALB2, ATM, etc.)?

Please specify mutation(s)

Have you had genetic testing (23andMe, Invitae, Color, clinical testing)?

Testing type and results (if known)

Lifestyle & habits

Height

Current weight

Goal weight or weight loss target (if applicable)

Tobacco / smoking use

Alcohol use

Recreational drug use

Physical activity level

Types of exercise you do or enjoy

Average sleep (hours/night)

Sleep quality

Current diet pattern

Daily stress level

Occupation / type of work

Anything else about your lifestyle relevant to your care?

Insurance information

We will verify your benefits and check coverage for your requested services. Many of our therapies are also available at competitive out-of-pocket rates regardless of insurance status.

Do you have health insurance?

Payment preference

How did you hear about CoreBalance Health?

Questions or notes for your provider

Consent & signature

By signing below, I confirm that the information provided is accurate to the best of my knowledge. I consent to evaluation and treatment at CoreBalance Health and authorize the release of information necessary for insurance billing and care coordination. I acknowledge that I have received and reviewed the CoreBalance Health Notice of Privacy Practices (HIPAA).

Full legal name *

Signature *

Today's date *

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CoreBalance Health

Personal information

Reason for visit

Medical history

Surgical history

Personal cancer history

Family cancer history

Lifestyle & habits

Insurance information

Consent & signature

Form submitted — thank you!

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