Patient Intake — EverVital Rx

1

Patient demographics

Basic identifying information for your clinical record

First name *

Last name *

Date of birth *

Biological sex at birth *

State of residence *

Height *

Current weight (lbs) *

Email address *

Phone number *

2

Primary treatment goals

Helps your provider match you to the right protocol

What are you hoping to address? * — select all that apply

Describe your goals in your own words

3

Medical history

Flags contraindications and informs safe prescribing

Previous surgeries or hospitalizations (include approximate dates)

Family history — has a blood relative been diagnosed with: *

⚠️ Family history of medullary thyroid carcinoma or MEN-2 syndrome is an absolute contraindication for GLP-1 receptor agonists.

Thyroid cancer or MEN-2 syndrome Medullary thyroid carcinoma Colorectal cancer Early-onset cardiovascular disease None known

4

Current medications & supplements

Identifies drug interactions and stacking risks

Current prescription medications *

OTC drugs and supplements

Currently taking insulin or a GLP-1 receptor agonist (Ozempic, Wegovy, Mounjaro)? *

Yes No Previously — stopped

Known drug allergies or adverse reactions *

5

Vital signs & recent labs

Allows provider to assess baseline eligibility without waiting for labs

🧪 If you have recent lab results, upload them after submission. The values below establish a baseline — labs older than 6 months may require a refresh before an Rx can be issued.

Fasting glucose (mg/dL)

HbA1c (%)

Total cholesterol (mg/dL)

Blood pressure — systolic

Blood pressure — diastolic

Resting heart rate (bpm)

IGF-1 (ng/mL, if known)

Testosterone (if known)

Date of most recent bloodwork

6

Lifestyle & health behaviors

Informs dosing strategy and protocol selection

Exercise frequency *

Primary exercise type

Diet quality — how would you rate your current diet? *

Very poorExcellent

Alcohol consumption *

Tobacco / nicotine use *

Recreational drug or controlled substance use *

No Occasionally Regularly Prefer not to answer

Average nightly sleep *

Under 4 hrs9+ hrs

7

Symptom & wellness inventory

Rate each on a 0 (none) – 4 (severe) scale to establish your baseline

8

Reproductive & safety screening

Required for safe prescribing of injectable compounded therapies

Currently pregnant, breastfeeding, or planning pregnancy in the next 6 months? *

Yes No N/A

History of anaphylaxis or serious allergic reaction to an injectable? *

Yes No

Prior use of peptides, SARMs, or performance-enhancing hormones? *

Yes No

If yes — which substances, and what were your results or reactions?

9

Provider eligibility summary

Auto-generated for the reviewing clinician upon submission

Clinical signal preview

This summary is visible to the patient for transparency. The reviewing provider sees a full structured report.

✓ Demographics, BMI, and weight history captured

✓ No absolute contraindications detected in current responses

⚠ Bloodwork date older than 6 months — updated labs may be required before Rx issuance

⚠ Current GLP-1 use indicated — provider to review stacking contraindications

✕ Family history of thyroid cancer noted — contraindicated for semaglutide / tirzepatide class peptides

○ IGF-1 and testosterone labs not provided — panel recommended before GH secretagogue protocols

✓ Patient consent and attestation collected

Your clinical intake starts here

Patient demographics

Primary treatment goals

Medical history

Current medications & supplements

Vital signs & recent labs

Lifestyle & health behaviors

Symptom & wellness inventory

Reproductive & safety screening

Provider eligibility summary