MY FLOW MD

Secure Health Intake Form

Please complete this form before your consultation. This allows our physician team to review your history and personalize your care plan.

1. Basic Information

Full Legal Name *

Date of Birth *

Sex *
MaleFemale

Phone Number *

Email Address *

Mailing Address

Street *

City *

State *

ZIP *

2. What Are You Interested In?

Medical weight lossHormone optimizationPeptide therapyLongevity / preventionEnergy & performanceMuscle gainSexual health

Other (please specify)

3. Current Height & Weight

Height (e.g., 5'10" or 178cm) *

Weight (lbs) *

4. Medical History

Have you ever been diagnosed with any of the following?

High blood pressureHigh cholesterolHeart diseaseStroke / TIAThyroid disorderAutoimmune diseaseCancerKidney diseaseLiver diseaseSleep apneaDepression / AnxietyADHDOsteoporosisChronic painNone

Other medical conditions

Surgical history (list procedures)

Hospitalized in the past 2 years? *
NoYes

If yes, please explain

5. Current Medications

Please list all prescription medications (include dose if known)

6. Supplements / Peptides

Please list all supplements or peptides you are currently taking

7. Allergies

No known drug allergies

Medication allergies

Food allergies

8. Family History (Important for GLP-1 Screening)

Do you or a family member have a history of:

Medullary thyroid carcinomaMEN2 (Multiple Endocrine Neoplasia Type 2)None

9. Lifestyle Overview

Exercise frequency *
None1-2x/week3-4x/week5+ times/week

Nutrition style *
StandardMediterraneanPaleoKetoVegetarianHigh proteinOther

Alcohol use *
None1-3 drinks/week4-7 drinks/week7+ drinks/week

Tobacco / nicotine *
NeverFormerCurrent

Sleep per night (hours) *

Stress level (1-10) *

10. Laboratory History

When were your most recent labs completed? (Month / Year)

11. Reproductive & Hormone History

Women:

Regular cyclesIrregular cyclesPregnant or trying to conceive

Men:

Prior low testosterone diagnosisPrior TRT useFertility concerns

12. Consent

I confirm that the information provided is accurate.

I understand that medical eligibility will be determined by a licensed physician.

I consent to communication via phone, email, or text regarding my care.

Electronic Signature (Type your full name) *