Female Wellness Intake Form -

Wellness Program Intake

Womens Wellness Program Intake

For women interested in our Foundation, Optimization, or Elite wellness programs. This intake gives Dr. Thomas the information she needs to recommend the right tier and design a safe, personalized hormone and longevity protocol.

🔒 Submissions are sent directly to Dr. Thomas’s clinical team via secure email. An initial consultation and lab work are required before any prescription can be issued.

Identity and Contact

Full name

Date of birth

Mobile phone

Age

Existing Sure Success Wellness patient?

Tier of Interest

Dr. Thomas may recommend a different tier based on your goals and history. Selecting one helps us start the conversation in the right place.

Foundation — $1,995 (3-month) Optimization — $4,495 (6-month) Elite — $8,995 (12-month) Not sure — please recommend

Your Goals

Describe your primary goal in your own words

Menstrual and Hormonal Status

Which best describes you?

Last menstrual period

Avg cycle length (days)

Period length (days)

Reproductive History

Pregnancies

Live births

Miscarriages

Have you had any of the following?

Current Symptoms (past 30 days)

Symptom Severity Rating

Rate each symptom group from 0 (none) to 4 (severe).

0 = None4 = Severe

Medical History

Please check anything that applies to you:

Other significant medical conditions or surgeries

Date of most recent mammogram (if applicable)

Past Hormone Therapy

Have you used hormone therapy or related medications before?

Never Currently using Used in past

If yes — type, dose, duration, and reason for stopping (if applicable)

Have you used any of the following?

Current Medications and Supplements

Prescription medications (name and dose)

OTC medications and supplements

Drug allergies and reactions

Lifestyle Baseline

Avg sleep hours per night

Exercise days per week

Stress level (1-10)

Current weight (lbs)

Height

Alcohol drinks per week

Tobacco use

Type of exercise

Recent Lab Work

Have you had recent (within 6 months) lab work — especially hormones, thyroid, or vitamin D?

Yes — I can share results Yes — do not have on hand No — would like labs ordered

If yes, which labs and any abnormal results you remember

Consent and Acknowledgment

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Please read carefully: Bioidentical hormone replacement therapy (BHRT) and related medications require ongoing medical supervision with regular bloodwork, mammograms, and bone, breast, and cardiovascular safety monitoring. Dr. Thomas will only prescribe what is appropriate for your individual case after an initial consultation and baseline labs.

Signature

Signature (type your full legal name)

Today’s date

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Intake Form Submitted

Your email client should have opened with your responses ready to send to Dr. Thomas’s team.

If nothing happened, please email your form directly to [email protected] or call us at (317) 253-7795.

A member of our team will reach out within one business day to schedule your consultation.