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Bio Hacking Luxe – Pre-Consultation Intake Form
(Confidential & HIPAA-Protected Health Information). Please complete before your appointment.
Patient Information
First Name
*
Last Name
Phone Number
*
Date of Birth
Email
Age
*
Sex
*
Address:
*
Emergency Contact
Please provide a next of kin's contact to contact incase of any emergencies. Make sure the contact is active.
First Name
Last Name
*
*
Email Address
Phone Number
*
Primary Goals & Concerns
Primary Goals & Concerns
Signs of aging (wrinkles, low energy, reduced recovery)
Low libido / sexual wellness concerns
Erectile dysfunction (men)
Menstrual cycle issues (women)
Fertility / pregnancy support (women)
Menopause / perimenopause management
Weight loss (fat reduction)
Muscle gain / strength building
Thinning hair / hair restoration
Brain fog / poor focus
Memory improvement
Mood support (depression, anxiety, stress, irritability)
Appetite control (suppress or increase)
Bone density concerns
Skin rejuvenation (texture, glow, anti-aging)
Stomach / digestion issues (IBS, bloating, discomfort)
Injury recovery - Specify Area
Faster post-workout recovery
Lifestyle optimization (longevity, wellness, vitality)
Detox
Other:
Current Health Information
Current Medications (list all, including over-the-counter & supplements):
*
Current Diagnosed Conditions (if any):
Current Medications & Supplements
*
Recent Surgeries / Injuries:
Family Health History (optional but helpful):
*
Lifestyle & Habits
-Occupation:
*
Exercise routine:
*
Exercise routine:
None
Light
Moderate
Intense
Sleep quality:
*
Sleep quality:
Excellent
Good
Poor
Alcohol Use
*
Alcohol Use
Never
Occassional
Regular
Tobacco Use
*
Tobacco Use
Never
Occassional
Regular
Stress Level
*
Stress Level
Low
Moderate
High
Diet Style (e.g., keto, balanced, high carb, vegetarian):
*
Interest in Services
*
Interest in Services
Genetic Testing – uncover your unique blueprint for health & performance
Hormone Replacement Therapy – restore balance & vitality
Peptide Therapy – healing, regeneration, and anti-aging
Weight Optimization Programs
Longevity & Anti-Aging Protocols
Skin & Hair Rejuvenation Treatments
Sexual Wellness Programs
Personalized Fitness & Nutrition Coaching
Other:
Consent
I acknowledge that Bio Hacking Luxe provides wellness and performance optimization services. This
intake form is for informational purposes only and does not replace professional medical advice.
Date
*
Signature
*
Signature
