Wellness Intake | PURE Medical Spa Chicago

Step 1 of 7

About You

Let's start with your basic information. All fields marked with * are required.

Full Name *

Please enter your full name.

Date of Birth *

Please select your date of birth.

Phone Number *

Please enter a valid 10-digit US phone number.

Email Address *

Please enter a valid email address.

Body Metrics

Used to calculate your BMI

Height (ft) *

Height (in)

Weight (lbs) *

Step 2 of 7

Medical Background

Help us understand your health history for a safe, personalised assessment.

Do you have any allergies?

Please list your allergies:

Have you had any surgeries?

Please list your surgeries:

Are you currently on any prescription medications?

Please list your medications:

Important Health Disclosures

Please answer honestly for your safety *

Has anyone in your family had pancreatitis? Has anyone in your family had medullary thyroid cancer? Are you currently pregnant, nursing, or planning to become pregnant? None of the above

Please select at least one option above.

Step 3 of 7

What Matters Most to You

Select the areas you want to optimize. This helps us design a program around your priorities.

Step 4 of 7

Energy & Sleep

Over the past 2 to 4 weeks, rate each symptom. Tap once to select, tap again to clear.

Energy Assessment

I feel tired most of the day

I wake up unrefreshed

I rely on caffeine to function

I experience afternoon crashes (1 to 4 PM)

My endurance / exercise capacity has declined

I feel burned out or depleted

Average sleep duration:

Sleep Assessment

Difficulty falling asleep

Wake up multiple times per night

Wake up too early (2 to 5 AM)

Light / easily disturbed sleep

Vivid dreams / restless sleep

Nighttime anxiety or racing thoughts

Snoring or possible sleep apnea

Step 5 of 7

Your Symptoms

Rate any symptoms you experience. Skip what does not apply to you.

Weight & Metabolic Status

Weight loss has plateaued

Regaining weight after initial loss

Difficulty losing abdominal fat

Low appetite but still not losing weight

Loss of muscle mass

Feeling metabolism has slowed

Are you currently using a GLP-1 medication?

Which medication?

Semaglutide Tirzepatide Other

GLP-1 side effects (if any):

Cognitive & Focus

Difficulty concentrating

Memory issues (short-term)

Mental fatigue

Slower thinking / processing

Reduced productivity

Brain fog sensation

Mood & Stress

Increased anxiety

Irritability

Feeling overwhelmed

Low resilience to stress

Emotional flatness

Reduced enjoyment in activities

Performance & Recovery

Slow recovery after exercise

Frequent soreness

Joint stiffness or pain

Reduced strength

Reduced endurance

Hormonal & General Health

Low libido Sleep disruption related to hormones Hot flashes / night sweats Hair thinning Skin thinning / aging concerns

Safety Screen

For provider review only

Unexplained rapid weight loss Severe depression or suicidal thoughts Chest pain / shortness of breath Neurologic symptoms Active cancer or under investigation

Step 6 of 7

Your Top Goal

Which program speaks to you most? Select up to 3 in order of priority.

Break through a weight plateau and optimize body composition

Sleep deeper and think sharper every day

More energy, vitality, and graceful aging

Healthier hair, stronger skin, and a younger look

Faster recovery and stronger physical performance

What would success look like for you in 8 to 12 weeks?

Step 7 of 7

Consent & Signature

Please review and agree to the following before submitting.

Your Signature *

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Today's Date

Wellness Program