Name:

Date of Birth:

Welcome to Integrative Lifestyle Medicine BayCare Clinic!

We are happy that you have chosen us for your care. Our goal is to work with you to achieve maximum

health and wellness.

Lynn Wagner, MD, is a fellowship-trained integrative medicine physician and a board-certified emergency

medicine physician. After practicing as an emergency medicine for more than 10 years, she followed her

passion for healthy living and holistic healing and offers her expertise in this field through our Integrative

Medicine Clinic.

Please complete the following intake form and bring it with you to your first appointment. All questions are

optional, but the more information you provide, the more Dr. Wagner will be able to help you achieve your

health goals. Dr. Wagner spends time getting to know you, reviewing your intake form and health records.

If you have extensive medical records from outside of Bellin Health or Prevea Health, please bring those

records and lab results. At your first appointment, we will determine the next steps, typically including a

follow-up to finalize your treatment plan. Please bring all non-prescription pills and supplements, as well as

this completed intake form, with you to your first appointment.

Dr. Wagner sets aside 60 minutes for her first visit with you. If you need to reschedule call 920.327.7056,

please do so as soon as possible to free up that time for others.

We look forward to meeting you,

Lynn K. Wagner, MD and Integrative Lifestyle Medicine Team

Name:

Date of Birth:

Patient Intake Form

Please complete this confidential form to the best of your ability. All questions are optional. The more

you share, the better I can help you.

• How did you hear of about BayCare Clinic’s® Integrative Medicine Program: circle one

social media // e-mail list // friend // family // spouse // event // doctor/referral // self

• What are your goals and expectations of this visit?

• If you are not feeling well, when was the last time you felt well? Did something trigger this change in

health?

Medical/Physical History*

*Feel free to skip listing your medical conditions and medications if you have recently updated your chart with

Aurora or BayCare Clinic.

• Do you have any current or prior medical problems/illnesses?

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Name:

Date of Birth:

• List any surgeries you have had:

• Have you ever been treated for a mental health/psychiatric condition? Yes // No

If yes, please specify.

• Please list your current medications and your supplements and bring them to the appointment.

(Include over-the counter, herbal medications, vitamins and medications that you only use

occasionally.) If you need more space please write on the back of the page.

Name Dose How Often Taken:

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Name:

Date of Birth:

• Please list any allergies or reactions to foods, medications or environmental allergies.

If you need more space please write on the back of the page.

Substance Allergy/Reacton

Bowel/Gut Health:

• Do you experience:

• Cramping: Yes // No • Excessive Flatulence: Yes // No

• Diarrhea: Yes // No • Constipation: Yes // No

• Heartburn: Yes // No • Do you feel like you digest your food well: Yes // No

• Bloating: Yes // No • Do you have normal regular bowel movements: Yes // No

How many servings of alcohol do you drink in a week?

Do you use any tobacco products? How often?

Do you use any recreational or street drugs? Explain.

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Name:

Date of Birth:

Diet:

• Please describe your typical day of food. List your breakfast, lunch, dinner and snacks. Some find it

helpful to write everything they ate in the last 24 hours. Be as specific and as honest as you can!

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Name:

Date of Birth:

• Are you currently following a diet or nutrition plan: Yes // No

• Have you ever been diagnosed with an eating disorder? Yes // No

• What diets have you tried in the past?

• Are there any types or groups of food you crave or overeat?

• What liquids do you drink during a typical day and how much?

• How many servings of fruit do you eat in a typical day?

• How many servings of vegetables do you eat on a typical day?

• Do you feel like you have a healthy relationship with food? If not, describe.

• Do you drink coffee? If yes, how much per day, and is it regular or decaffeinated?

• Do you drink soda? If yes, how much per day? Is it regular or diet?

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Name:

Date of Birth:

Fitness:

• Do you follow any regular exercise program(s)? If yes, please describe the type of exercise and how

often/how long you do the exercise(s):

• Do you have any limitations to exercise (pain, shortness of breath etc.)?

• Do you feel energized or fatigued after you exercise? Energized // Fatigued

Sleep/Rest:

• Describe how you sleep (in general):

• How many hours do you sleep on average?

• Check all that apply to you: Trouble falling asleep Wake up during night Don’t feel rested

• Do you snore? Yes // No

• Does lack of sleep affect your daily activities?

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Name:

Date of Birth:

Environment:

• Do you feel you live and work in a physical environment that is peaceful, uncluttered and supports

your overall well-being? Does your environment feel peaceful to you?

• Do you try to eat some or mostly organic food? Yes // No // Sometimes

• How often do you spend time in nature or outside? Name activities.

Work/Play:

• Do you work outside of the home? If yes, what is your occupation?

• Are you satisfied with your current occupation? Explain why or why not.

• Do you feel that your life has purpose and meaning?

• Are you aware of (can you name) your gifts and talents?

• Do you have passions and hobbies you can identify?

• Do you feel financially secure? Yes // No

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Name:

Date of Birth:

Mind/Emotional well being:

• Please describe your mood.

• Would you describe your mood as stable? Why or why not?

• Please list any major traumatic or life changing events (emotional, verbal, physical or sexual) you have

experienced. Describe.

• Do you deal with these memories in a healthy way?

• What do you do for relaxation/coping? Describe. (meditation, prayer, etc.)

• Do you express your feelings freely? Explain.

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Name:

Date of Birth:

Relationship History:

• What is your housemates/living situation?

• To whom do you turn for support in time of need?

• Do you have friends or loved ones who you can play and share life with on a frequent basis?

• Do you have a loving, respectful relationship with yourself?

• If you are in a relationship, do you have a loving, open, respectful relationship with your spouse or

significant other?

• Do you have barriers to intimacy with your spouse or other loved ones?

Reproductive/Sexual History (women):

• When was your last period?

• Are you currently using protection/birth control? Yes // No

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Name:

Date of Birth:

• Describe your menstrual cycle (How many days, any problems/concerns, bleeding abnormalities).

• If you are post-menopausal, do you have any significant concerns or symptoms related to menopause

(hot flashes, mood swings, brain fog)?

• Are you satisfied with your current sex life/sexuality?

• Do you having any problems with libido, orgasm or any other sexual difficulties?

Sexual History (men):

• Do you have difficulty obtaining or maintaining an erection?

• Are you satisfied with your current sex life/sexuality?

• Do you having any problems with libido, orgasm or any other sexual difficulties?

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Name:

Date of Birth:

Spiritual History:

• Describe your religion/spirituality.

• Do you nuture your spiritualty?

• Do you have a regular ritual of prayer or meditation?

• List any additional information you would like to share with the doctor today.

If you have additional questions while filling out this form, please contact us at: 920.327.7056

For more information on Dr. Lynn K. Wagner, what to expect during your visit, her practice and her programs,

please check out: www.lynnkwagner.com

Date this form was completed: ________________________

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