Client Intake Form

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Client Intake Form

We need to know your health history and expectations at Thrive by K. Begin your wellness journey with Kristin Gustin by completing the Client Intake Form below.

Email *

Patient Name: (Last) (First) (MI) *

Patient Address (with City, State, Zip): *

Phone Number: *

Birthdate: *

Age: *

Height: *

Weight: *

Gender assigned at birth *

Female

Male

Occupation: *

How did you hear about us? If referred by a friend please list their name. *

Are you under the care of a qualified healthcare provider? Please list their names and the medical facility they work with: *

Emergency Contact:

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Medical History

Please list any allergies or sensitivities: *

Please list any medical conditions a medical provider has diagnosed you with in the past (such as high blood pressure, diabetes, arthritis, etc…): *

What medications do you take regularly or are currently prescribed? List name and dosage: *

What supplements and over-the-counter items do you take regularly: *

Any past surgeries and hospitalizations? Please list: *

Please describe your family history in terms of heart disease, diabetes, obesity, high cholesterol, high blood pressure, and cancer: *

Sign and Submit Intake Form

As detailed in the Consent portion, it is highly recommended that you are under the care of a qualified healthcare professional, who has verified that it is safe for you to exercise and be on a weight loss program and is monitoring medications and any health concerns that you list here (besides your weight issues- that’s what we’re covering). If you are on medications (particularly for high blood pressure, heart issues, or diabetes), you will need these to be monitored during and after the program as your need for them may change.

Please type your full name to acknowledge the above statement above:

Send me a copy of my responses.

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