📋 General Wellness Intake Form 1

💉 Peptide-Specific Intake Form 2

📈 Follow-Up Assessment Form 3

WellSourced

✦ Certified Practitioner

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New Client Wellness Intake

Please complete this form before your first session. All information is kept strictly confidential.

This form is for educational consultation purposes only. The information collected helps your WellSourced Certified Practitioner understand your wellness background and goals. This is not a medical intake form and does not create a patient-provider relationship.

Personal Information

Full Name

Date of Birth

Email Address

Phone Number

Today's Date

Occupation / Role

How did you hear about us?

Health History Overview

Current primary care physician or specialist (if applicable)

Current medications (name + reason, if comfortable sharing)

Relevant medical history — diagnoses, past surgeries, chronic conditions

Known allergies or sensitivities

Current diagnosed conditions

Current Supplement Stack

Supplement / Product	Dose / Frequency	How Long	Why

Wellness Goals

Primary wellness goal — what brings you here?

Secondary goal(s)

What have you already tried?

What topics are you most interested in learning about?

Peptide science & research Recovery & tissue repair (musculoskeletal) Metabolic health & body composition Cognitive performance & brain health Immune function & resilience Hormonal balance & longevity Gut health & GI function Other:

Lifestyle Snapshot

Sleep quality (1–10)

1 2 3 4 5 6 7 8 9 10

Energy levels (1–10)

1 2 3 4 5 6 7 8 9 10

Stress level (1–10)

1 2 3 4 5 6 7 8 9 10

Exercise frequency

Rarely 1–2x/week 3–4x/week 5+/week

Diet approach

Alcohol / caffeine use

Additional Notes

Anything else you'd like your practitioner to know?

WellSourced

✦ Certified Practitioner

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Your Practice Name

Peptide Education Intake

For clients seeking education on peptide research. Complete before your first peptide-focused session.

This form is for peptide-specific educational consultation only. Information shared helps your WellSourced Certified Practitioner tailor research education to your background. This does not constitute medical advice or a prescribing relationship.

Client Information

Full Name

Date of Birth

Today's Date

Referring practitioner / source

Prior Peptide Experience

Have you researched or used peptides before?

No prior experience — completely new Some research but no personal use Have used peptides in the past Currently using peptides

If you've used or researched peptides, which ones? (list each)

Source(s) of previous peptide information

Online research / forums (Reddit, etc.) Medical provider / functional MD Health coach / practitioner Published scientific literature Biohacking community / podcasts Other:

What is your current level of knowledge about peptides?

Beginner — heard the term, want to understand basics Intermediate — understand mechanisms, exploring options Advanced — familiar with research, want expert review

Contraindications Screening

This section helps identify any medical factors your practitioner should be aware of when providing educational context.

Any conditions checked above — provide details:

Current medications that may interact with peptide education topics (hormone therapies, immunosuppressants, insulin, growth hormone therapies)

Current Protocol (If Applicable)

Peptide / Compound	Dose	Frequency / Route	Source (prescribed/research)	Duration

Education Goals

What outcome are you hoping to achieve through peptide education?

WellSourced

✦ Certified Practitioner

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Follow-Up Assessment

Returning client — track progress, review changes, and set next session goals.

Session Details

Client Name

Session Date

Session # (this visit)

Last Session Date

Time Since Last Session

Progress Since Last Session

What changes (positive or neutral) have you noticed since our last session?

Have you implemented any of the research or education from our last session?

Yes — tell us what below Partially — still researching No — reasons below

Details on what you implemented or why you haven't yet:

Current Status Check-In

Overall wellbeing (1–10)

12345678910

Energy (1–10)

12345678910

Sleep quality (1–10)

12345678910

Side Effects or Concerns

Have you noticed any side effects or adverse reactions to anything since our last session?

No side effects to report Minor effects — describe below Significant effects — describe below (consider consulting a physician)

Side effects or concerns — detail:

Protocol Changes Since Last Session

Changed Item	What Changed (dose, stopped, added)	When Changed	Effect Noticed

Goals for This Session

What do you most want to cover in today's session?

Progress toward your original goal(s)

Significant progress — on track Some progress — adjustments needed Limited progress — need new approach Goals have changed — discuss today

Updated primary goal (if changed)

Practitioner Notes (Practitioner Use Only)

Session notes, action items, next session recommendations:

Next session date

Follow-up items

Practitioner initials