Preventative Health Intake Form
Welcome! 

Thank you for your interest in the VitaMed LA Wellness Program.

This brief health assessment helps us better understand your medical history, current health concerns, and wellness goals so we can make the most of your consultation.

After reviewing your responses, our team will contact you to schedule your initial 40-minute consultation. During this visit, we'll discuss your health in detail and determine which laboratory tests and additional evaluations are appropriate for you.

Our goal is to create a personalized wellness plan that complements your primary care—not replaces it—using advanced laboratory testing, evidence-informed recommendations, and ongoing support to help you optimize your long-term health.

The form typically takes 5–10 minutes to complete.

Please note: Completing this form does not establish a patient-provider relationship or guarantee treatment. All recommendations will be made after your consultation and appropriate medical evaluation.

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Legal Name (as seen on Driver's License) *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Phone Number *
Email Address *
What brings you to us?
What are your top 3 health goals?
Past Medical History *
Required
If you would like to elaborate on you health history here, feel free.
Family History *
Current Medications (with Dosing) *
Past Medications (if Relevant)
Current Supplements / Peptides
Have you used any peptides in the past? If yes, please list them.
Drug Allergies *
Are you pregnant? *
Are you breastfeeding? *
Height *
Weight *
Goal Weight (if relevant)
Social History
Exercise?
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Sleep?
Specific Supplements / Medication / Peptides Interested in, if any?
Do you have bloodwork from the last year? If so please email them to info@vitamedla.com SUBJECT LINE: "'YOUR NAME' LABS"
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How were you referred to us? *
Submit
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