
1. Preferred name/pronouns; phone number; email; safe way to contact you?
2. Home address, city, state and ZIP code?
3. Where will you physically be during visits? Give address/state; update at every visit.
4. Emergency contact: name, relationship, phone; may we contact them if needed for safety?
5. Primary care clinician and preferred pharmacy: names, locations and phone numbers?
6. Which service(s) are you requesting? What are your main goals?
7. Do you have video access, a private space and a reliable callback phone?
8. Language, interpreter, disability or technology accommodations needed?
9. Insurance/self-pay preference; referring clinician; who helped complete this form?
10. Current diagnoses and major past illnesses, including approximate dates?
11. Heart disease, high BP, stroke, blood clots, fainting or unexplained chest symptoms?
12. Diabetes, kidney/liver disease, thyroid problems, sleep apnea or cancer history?
13. Mental health diagnoses, hospitalizations, current therapy or prior treatment?
14. Any thoughts of harming yourself or others, or recent episodes of feeling unsafe? Explain.
15. Tobacco/nicotine, alcohol, cannabis or other substance use; current/past treatment?
16. Pregnant, possibly pregnant, trying to conceive or breastfeeding? Relevant reproductive history?
17. Surgeries, hospital stays, family medical history or recent major health changes?
18. Current sleep, daily function and any other concern you want to discuss privately?
19. Allergies: substance/drug, reaction, severity and approximate date. If none known, state that.
20. Current prescriptions: name, strength, how taken, reason and prescriber. Add a secure list if needed.
21. Over-the-counter medicines, vitamins, herbs, supplements, creams and injections?
22. Recently stopped medicines and why; side effects or medicines you could not tolerate?
23. Any trouble getting medicines, paying for them, remembering doses or using devices?
24. Other clinicians, specialists, counselors or dietitians involved in your care?
25. Recent labs, imaging, relevant records: test/date/location; can you provide copies?
26. Home BP, pulse, weight or glucose devices; latest readings and dates, if known?
27. Anything else needed for medication safety, including pharmacy or prescribing concerns?
1. Which symptoms concern you, when did they begin, and how do they affect daily life?
2. Prior low-testosterone diagnosis, morning blood tests, dates, values and testing location?
3. Current/past testosterone or hormone treatment: product, prescriber, response and side effects?
4.Fertility goals: trying to conceive now or in the future? Any infertility treatment?
5. Sleep apnea, snoring, poor sleep, opioid/steroid use or other possible contributors?
6. Prostate/breast cancer, prostate symptoms, high blood counts, clots, stroke or heart disease?
7. Recent BP, weight, blood tests or prostate evaluation; dates and clinician?
8. Preference or concerns about injections, gel or other options; ability to monitor at home?
9. What result matters most? Questions about risks, fertility, alternatives or ongoing costs?
1. Main concerns: hot flashes, night sweats, sleep, mood, dryness, pain or other symptoms; timing?
2. Age at last menstrual period and date; cycle changes; any unexplained or postmenopausal bleeding?
3. Do you have a uterus and ovaries? Prior hysterectomy or other reproductive procedures?
4. Pregnancy possibility, contraception, fertility plans or breastfeeding?
5. Past/current hormone therapy, birth control or vaginal treatment; benefit and side effects?
6. Personal/family breast or uterine cancer; blood clots, stroke, heart or liver disease?
7. Vaginal/urinary symptoms, painful sex or sexual-desire concerns you want to discuss?
8. Recent mammogram, cervical screening, pelvic evaluation or relevant tests: dates/results?'
9. Treatment goals, preferred options and questions; anything to discuss privately?
1. Height, current weight, dates measured and weight changes over the past year?
2. Goals and reasons for seeking care; previous programs, medicines and results?
3. Usual meals/snacks, activity, sleep and barriers such as schedule, cost or food access?
4. Diabetes, high BP, sleep apnea, heart/kidney/liver disease or other relevant conditions?
5. Pancreatitis, gallbladder disease, severe digestive symptoms or prior weight-loss surgery?
6. Personal/family medullary thyroid cancer or MEN2? If unsure, state that.
7. Pregnancy possibility, plans to conceive or breastfeeding?
8. Bingeing, purging, restrictive eating, body-image distress or an eating-disorder history?
9. Current medicines, prior weight-drug side effects, home measurements and treatment preferences?
1. Diabetes type, diagnosis date, treating clinicians; any uncertainty about the diagnosis?
2. Latest A1C and date; recent home glucose ranges, timing and checking method?
3. Diabetes medicines/insulin: doses, timing, missed doses, side effects and access concerns?
4. Low-glucose episodes, symptoms, need for help or emergency treatment; when and how often?
5. High-glucose episodes, ketones, ketoacidosis, vomiting or hospitalizations?
6. Kidney, heart, nerve, eye or foot problems; wounds or recent changes?
7. Dates/results of kidney testing, eye exam, foot exam and cholesterol testing?
8. CGM/pump use, device support needs, pregnancy possibility or breastfeeding?
9. Usual meals/activity, education needs, sick-day questions and goals for care?
1. When was high BP diagnosed? Current clinicians and prior treatment?
2. Home monitor make/type/cuff size; how and when do you measure BP?
3. Recent readings with dates/times, pulse and symptoms; attach a secure log if available.
4. Current BP medicines, doses, timing, missed doses, side effects and access concerns?
5. Chest pain, breathing trouble, weakness, vision changes, dizziness or fainting?
6. Kidney disease, heart disease, stroke, sleep apnea or family cardiovascular history?
7. NSAIDs, decongestants, stimulants, supplements, nicotine, alcohol or caffeine use?
8. Pregnancy possibility; recent kidney/electrolyte tests and other relevant records?
9. Food/sodium habits, activity, goals and ability to obtain labs or local assessment?
1. Which joints hurt, when did symptoms begin, and were you given a specific diagnosis?
2. Pain level 0-10; activities affected; morning stiffness duration?
3. Swelling, warmth, redness, injury, fever or sudden inability to use/bear weight on a joint?
4. Prior imaging/labs, joint procedures or surgery; dates, findings and clinicians?
5. Current/past medicines, creams, injections, therapy or exercises; response and side effects?
6. Stomach ulcers/bleeding, kidney disease, high BP, heart disease or blood thinner use?
7. Rheumatoid/psoriatic arthritis, gout, psoriasis, autoimmune disease or family history?
8. Rheumatologist/orthopaedist involved; disease-modifying medicines and monitoring?
9. Functional goals, assistive devices, weight concerns and local-care access?
1. Attention, organization, impulsivity or restlessness concerns; onset and daily impact?
2. Were symptoms present before age 12? Examples, school history or available records?
3. How do symptoms affect at least two areas: work/school, home, relationships or daily tasks?
4. Prior ADHD diagnosis/testing, clinicians and collateral information available?
5. Past/current ADHD medicines or therapy; benefits, adverse effects and reason for stopping?
6. Sleep problems, anxiety, depression, trauma, mania/psychosis or other possible contributors?
7. Current/recent alcohol, cannabis, stimulants or other substance use; any misuse concerns?
8. Heart disease, fainting, high BP, family sudden cardiac death; latest BP, pulse and weight?
9. Goals, support/coaching needs, pregnancy possibility and other questions for the clinician?
1. Areas affected, onset, itch/pain severity and effect on sleep or daily life?
2. Prior eczema diagnosis; seasonal pattern; asthma, allergies or family history?
3. Current skin-care routine, moisturizers, bathing habits and products used?
4. Prescribed/OTC creams: names, strengths, application sites, frequency and duration?
5. Previous treatments, improvement, irritation or other adverse effects?
6. New exposures, products, work chemicals, jewelry, medicines or suspected triggers?
7. Blisters, pus, crusting, spreading redness, warmth, fever, eye symptoms or feeling unwell?
8. Clear photos available; prior dermatologist visits/testing or recurrent skin infections?
9. Pregnancy/breastfeeding, treatment goals, access/cost barriers and private concerns?
1. When did hair loss begin? Gradual thinning, sudden shedding, patches or another pattern?
2. Areas affected; itching, pain, scaling, redness, sores or suspected scarring?
3. Recent illness, surgery, major stress, childbirth, restrictive diet or significant weight change?
4. Family hair-loss history; menstrual changes or other hormonal symptoms if relevant?
5. Current/past minoxidil, finasteride, spironolactone, supplements or other treatment?
6. Benefits and adverse effects, including dizziness, swelling, sexual or mood changes?
7. Pregnancy possibility, trying to conceive or breastfeeding?
8. Heart/kidney disease, BP problems, recent labs and prior dermatology diagnosis?
9. Goals, treatment preferences and ability to provide consistent scalp photos?
1. What condition or symptoms are you seeking help for? Current treating clinician?
2. Past psychiatric diagnoses, hospitalizations and prior antidepressant/therapy trials?
3. Any current thoughts of harming yourself/others, unsafe behavior, mania or psychosis?
4. Previous ketamine/Spravato: formulation, setting, prescriber, benefit and adverse effects?
5. Current medicines, sedatives, opioids, alcohol/cannabis or other substance use?
6. High BP, heart/vascular disease, breathing problems, sleep apnea, liver or bladder symptoms?
7. Pregnancy possibility, conception plans or breastfeeding?
8. Are you seeking lozenge evaluation, nasal-treatment referral or follow-up coordination?
9. Local treatment center, support/transport access and questions about supervision or safety?
1. Nutrition goals, relevant medical conditions and current treating clinicians?
2. Usual meals, snacks, drinks and meal timing on a typical day?
3. Food allergies/intolerances, dietary restrictions, cultural preferences or foods you avoid?
4. Food access, grocery budget, cooking resources, schedule and household support?
5. Recent weight changes, appetite, swallowing/digestive symptoms or unintended weight loss?
6. Bingeing, purging, restrictive eating or past/current eating-disorder care?
7. Medicines, vitamins/supplements and prior nutrition or dietitian treatment?
8. Activity/sleep habits; recent glucose/BP/labs if relevant; meal-planning barriers?
9. Would you prefer general coaching or dietitian-led condition-specific care? Main questions?
Review symptoms, medications, sleep, health history and fertility goals.
Arrange appropriate baseline hormone testing and additional testing when indicated; local testing or an examination may be needed.
Discuss other possible causes of symptoms and suitable treatment options
Follow up on symptoms, laboratory results, side effects and treatment response.
Review your history, medications, and previous testing
Coordinate local nerve, strength, or foot examinations when needed
Discuss suitable treatment and medication monitoring
Support foot protection, balance, sleep, and daily function
1. Where do you feel numbness, tingling, burning or pain, and when did it begin?
2. Are symptoms on one side or both, and are they changing?
3. Any new weakness, falls, balance problems or trouble walking?
4. Any wounds, color changes or reduced feeling in your feet?
5. Have you been diagnosed with diabetes, vitamin deficiency, kidney disease or another possible cause?
6. What medicines, supplements, alcohol use or prior chemotherapy should the clinician review?
7. What tests, examinations or treatments have you had, and did they help?
8. How do symptoms affect sleep and daily activities, and what are your goals?
Review symptoms and assess other or coexisting conditions
Create a gentle activity, pacing, and sleep-support plan
Discuss appropriate medication options and side effects
Coordinate physical therapy or behavioral therapy when helpful
1. Where do you experience pain, and how long has it been present?
2. Have you received a fibromyalgia diagnosis, and what evaluation was done?
3. How are fatigue, sleep, concentration and daily activities affected?
4. Do you have joint swelling, fever, unexplained weight changes or new weakness?
5. What other medical or mental health conditions are being treated?
6. Which medicines, activity programs or therapies have you tried, with what benefits or side effects?
7. What activities trigger flares, and what helps you recover?
8. What are your main goals for function, sleep and symptom control?
One scheduled video follow-up
Medication & side-effect review
Pain, sleep & function tracking
Self-care and referral coordination
Messaging during clinic hours
One scheduled video follow-up
Medication & side-effect review
Pain, fatigue & sleep review
Activity and pacing guidance
Messaging during clinic hours
One combined video follow-up
Coordinated medication review
Shared goals for pain & function
Self-care and referral coordination
Messaging during clinic hours
No. A video visit cannot reliably replace every neurologic, sensory, circulation, or joint examination. Your clinician may arrange local testing, an examination, or specialist care before recommending treatment.
Depending on the diagnosis and individual risks, options may include duloxetine, pregabalin, or selected other medicines. Gabapentin and topical treatments may be options for certain nerve-pain conditions; milnacipran is an option for fibromyalgia. Some uses are off-label. Medication choice and monitoring are individualized, and medication costs are separate.
No single blood test or scan confirms fibromyalgia. Evaluation considers the symptom pattern and other possible or coexisting conditions. Your clinician may recommend a local examination or targeted tests.
The proposed care workflow uses review within 2–4 weeks after medication changes, sooner when needed. Your clinician sets the interval based on your situation. Ongoing plans include one scheduled monthly video follow-up.
Neither outcome is guaranteed. Neuropathy treatment addresses contributing causes when possible and supports pain relief and safety. Fibromyalgia treatment focuses on symptom management and improvements in function, sleep, and daily participation.
This is a program preview. Online booking and enrollment are not available on this page. Review the intake questions under each service or download the fillable packet. No payment or medical information is collected here.