JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Vibe Wellness Intake Questionnaire
This will give Dr. Stacy the information she needs to make personalized recommendations for you!
FYI Dr. Stacy is not able to accept insurance for testing or care so please consider this.
(We can, however, accept most HSA/FSA accounts)
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Full Name
Your answer
Shipping Address
*
Your answer
Date of Birth
MM
/
DD
/
YYYY
Sex
*
Male
Female
Occupation
Your answer
Describe the concerns you are having with your health
Your answer
What treatments have you tried
Your answer
Have any of them been successful?
Your answer
Past medical and surgical history:
Your answer
Past antibiotic/steroid use: (including childhood)
Your answer
Current Medications:
Your answer
Vitamins, Minerals, or Nurtritional Supplements currently taking:
Your answer
How many bowel movements (BM) do you have per day? Example: 0-1, 1-2, 3 or more
0-1
1-2
3+
Clear selection
How would you rate your current level of stress?
1
2
3
4
5
6
7
8
9
10
Clear selection
Women: If you have a cycle, how long is it and is it regular?
Your answer
Women: Do you have any problematic symptoms related to your cycle?
Your answer
List your hobbies and leisure activities:
Your answer
Do you struggle with insomnia or interrupted sleep?
Your answer
Do your parents or siblings have (or had) any health issues? If so, please explain:
Your answer
Anything else I should know?
Your answer
Thank you SO much for filling this all out, Dr. Stacy will be in touch within 1-2 business days! If you haven't already, please make sure you allow replies and emails from stacy@dr-stacy.com (or check your spam if you haven't heard back in this timeframe!)
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Dr. Stacy.
Does this form look suspicious?
Report
Forms
