Purser Wellness Patient Intake

What type of appointment is this intake for? Required

Nutritional Coaching CMA or Nutrient Appointment Genetics Appointment Follow-Up

Patient

Basic information

Required fields marked *

Full legal name * Preferred name Date of birth * Sex recorded at birth * Gender identity optional Height / weight optional Phone * Email * Street address * City * State * ZIP code * Primary care provider Referring provider optional Preferred pharmacy optional Pharmacy phone / location optional Occupation optional Marital status optional How did you hear about us? optional Family or friends seen here? optional

Optional: Add me to the Purser Wellness email list.

Safety contact

Emergency contact

Contact name * Relationship to patient * Phone * Email optional

May Purser Wellness share necessary medical information with this emergency contact when needed? *

Yes No

Main reason for coming to Purser Wellness * What would you most like to improve over the next 90 days? *

Health priorities

Your most important concerns

Add at least one concern. You may add up to three.

Tell us the story of your symptoms in your own words optional Previous evaluations, diagnoses, treatments, or protocols tried optional

What helped? optional What did not help? optional

Questions for the Purser Wellness team optional

This section is optional except for allergies

You may skip medications and supplements. Every patient must answer the allergy question below.

Required safety question

Do you have any known allergies, sensitivities, or serious reactions?

YesI have allergies or sensitivities. No known allergiesI do not know of any. UnsureI am not certain.

Medication or supplement reactions / side effects we should know about optional

Optional

Current medications

Include prescriptions, over-the-counter medications, hormones, injections, topical medicines, and as-needed medicines when available.

Optional

Current supplements

Medication or supplement questions / concerns optional I am choosing not to provide medication and supplement details in this intake.

Short answers are okay

Each gateway question is required. Choosing No, Unsure, or Unknown counts as a complete answer.

Medical events

Surgeries, hospital stays, major injuries, or major illnesses

Have you had a major medical event? *

Yes No Unsure

Family history

Major health conditions in close relatives

Examples include autoimmune disease, cancer, heart disease, diabetes, dementia, hormone disorders, clotting issues, high homocysteine, MTHFR, and inflammatory conditions.

Are there major health conditions that run in your close family? *

Yes No clear pattern I do not know my family history

Care team

Specialists or other health professionals

Are you currently seeing specialists or other health professionals? *

Yes No Unsure

Other medical history notes optional

Optional section

Answer any questions that may help, or use Skip this section. You can return from the review page.

Which three symptoms affect your life the most? When are symptoms best or worst? Include patterns after meals, exercise, stress, sleep, or supplements. Other symptoms or patterns not listed

Optional section

Answer what feels useful. Nothing on this page is required.

Describe your usual diet, restrictions, preferences, or eating window

Typical breakfastTypical lunchTypical dinnerTypical snacksBeverages / hydration

Caffeine: type / amountAlcohol: type / amountTobacco / nicotine / vapingRecreational substancesExercise type / days per weekAverage daily activity levelAverage bedtime / wake timeHours of sleep per nightStress level 1-10Top current stressorsSleep details: falling asleep, staying asleep, snoring, waking unrefreshed, or naps

Optional section

This intake does not accept lab or document uploads. Use your office's existing secure process for records.

Approximate dates of previous testingKnown genetic factors (for example: MTHFR, MTR/MTRR, CBS, PEMT, COMT, SOD, GST, or family high homocysteine)Previous results or supplement protocols that helped or did not helpAdditional records, context, or clinical details

Read and acknowledge each agreement

Each policy has its own acknowledgment. One final electronic signature applies to all acknowledged agreements.

Optional billing information

You do not need to complete this section

Optional

Leaving billing blank will not prevent submission or affect your appointment. This intake never asks for a complete card number, expiration date, or security code.

Skip billingDo not provide billing information here. Use a card already on fileAuthorize the office to use an existing card. Have the office contact meCollect payment details through the approved process.

Final electronic signature

Sign this completed intake

Printed full legal name *Type your name as your signature *Who is signing? *Relationship to patient

Drawn signature optional

Use a mouse, trackpad, or finger. Your typed signature above is still required.

I intend my typed name and final submission to serve as my electronic signature for this intake and every agreement I acknowledged above.

New Patient Intake & Agreements

Answer one section at a time

Review before sending

Send once and download

Do not use this form for an emergency

Patient Information

What type of appointment is this intake for? Required

Basic information

Emergency contact

Parent or legal guardian

Your most important concerns

This section is optional except for allergies

Do you have any known allergies, sensitivities, or serious reactions?

Current medications

Current supplements

Short answers are okay

Surgeries, hospital stays, major injuries, or major illnesses

Major health conditions in close relatives

Specialists or other health professionals

Optional section

Digestive details

Hormone, menstrual, fertility, thyroid, mood, or energy notes

Optional section

Optional section

Read and acknowledge each agreement

You do not need to complete this section

Sign this completed intake

Review your intake before sending

Final submission

You're all set.

Office copy received

Download your copy

Labs stay separate

Save your completed intake

New Patient Intake & Agreements

Answer one section at a time

Review before sending

Send once and download

Do not use this form for an emergency

Before you begin

Patient Information

What type of appointment is this intake for? Required

Basic information

Emergency contact

Parent or legal guardian

Reason for Visit

Your most important concerns

Medications, Supplements, and Allergies

This section is optional except for allergies

Do you have any known allergies, sensitivities, or serious reactions?

Current medications

Current supplements

Medical and Family History

Short answers are okay

Surgeries, hospital stays, major injuries, or major illnesses

Major health conditions in close relatives

Specialists or other health professionals

Symptoms and Health Patterns

Optional section

Digestive details

Hormone, menstrual, fertility, thyroid, mood, or energy notes

Lifestyle and Diet

Optional section

Previous Testing

Optional section

Policies, Billing, and Signatures

Read and acknowledge each agreement

You do not need to complete this section

Sign this completed intake

Review your intake before sending

Final submission

You're all set.

Office copy received

Download your copy

Labs stay separate

Save your completed intake