Initial Information

AllySera — General Medical Intake

AllySera General Medical Intake · Body Container v0.1

Section 1 of 14

Sections

Section 1

Basic Health Profile

Foundational context — who you are in relation to your health.

What is your age? body.basics.age_range

What was your sex assigned at birth? body.basics.sex_assigned_at_birth

Male Female Intersex Prefer not to say

Do you identify as a gender different from your sex assigned at birth? (Relevant to some health questions.) body.basics.gender_health_relevance

Yes No Prefer not to say

What is your primary language? body.basics.primary_language

Do you currently have a primary care physician or GP? body.basics.has_primary_care_provider

Yes No

When was your most recent physical exam or check-up? body.basics.last_physical_exam

Within 6 months Within 1 year 1–2 years ago 3–5 years ago More than 5 years ago Don't remember

Do you currently have health insurance? body.basics.insurance_status

Yes No

What type of coverage do you have? body.basics.insurance_type

Employer Private/ACA marketplace Medicaid Medicare VA / Military Other

Are there barriers that make it difficult for you to access healthcare when you need it? body.basics.healthcare_access_barriers

Section 2

Current & Ongoing Conditions

Health conditions that are actively part of your life right now.

Note — You don't need to use medical terminology. Your own words are fine.

Do you have any chronic health conditions — health issues that are ongoing and that you manage regularly? body.conditions.has_chronic_conditions

Yes No

Please list any chronic conditions you manage. Use your own words — you don't need medical terminology. body.conditions.chronic_conditions_list

How long have you been managing these conditions? body.conditions.condition_duration

Less than 1 year 1–5 years 5–10 years More than 10 years Most of my life

Would you say your conditions are currently stable, improving, or getting worse? body.conditions.condition_stability

Stable Improving Getting worse Mixed / depends

Have you received any new diagnoses in the past 12 months? body.conditions.recent_diagnosis

Yes No

Please describe the new diagnosis or diagnoses. body.conditions.recent_diagnosis_detail

Are there significant health conditions from your past that are now resolved? body.conditions.past_conditions_resolved

Yes No

Briefly describe. body.conditions.past_conditions_resolved_detail

How much do your health conditions affect your ability to go about your daily life? body.conditions.conditions_impact_daily_life

Not at all Slightly Moderately Significantly Severely

Section 3

Medications & Supplements

Current prescriptions, OTC medications, vitamins, supplements.

Note — You don't need exact medication names. Descriptions are fine. Dosages are not required.

Are you currently taking any prescription medications? body.medications.takes_prescription_medications

Yes No

Please list the medications you take. (Name or description, condition it's for, and how often — as much as you're comfortable sharing.) body.medications.prescription_list

Do you take any over-the-counter medications regularly? (e.g. pain relievers, antacids, sleep aids) body.medications.takes_otc_medications

Yes No

Please describe. body.medications.otc_list

Do you take any vitamins or supplements? body.medications.takes_supplements

Yes No

Please list. body.medications.supplement_list

Are you generally consistent about taking your medications as prescribed? body.medications.adherence

Yes, consistently Mostly Sometimes — it's complicated Not consistently N/A — no prescriptions

Do you have any concerns or questions about your current medications? body.medications.medication_concerns

Section 4

Allergies

Medication allergies, food allergies, environmental allergies, and documented reactions.

Do you have any known allergies to medications? body.allergies.has_medication_allergies

Yes No

Please list any medications you're allergic to and the reaction, if known. body.allergies.medication_allergy_list

Do you have any food allergies or significant food intolerances? body.allergies.has_food_allergies

Yes No

Please list any food allergies or intolerances. body.allergies.food_allergy_list

Do you have any environmental allergies? (e.g. pollen, dust, animals, latex) body.allergies.has_environmental_allergies

Yes No

Please list any environmental allergies. body.allergies.environmental_allergy_list

How severe are your allergies overall? body.allergies.allergy_severity

No allergies Minor irritation Significant reactions Anaphylactic — emergency-level

Section 5

Surgical & Procedural History

Past surgeries, significant procedures, and hospitalizations.

Have you had any surgeries? body.procedures.has_surgical_history

Yes No

Please list any surgeries — type of surgery and approximate date, if you remember. body.procedures.surgical_history_list

Have you had any other significant medical procedures? (e.g. biopsies, cardiac catheterization, endoscopy) body.procedures.has_significant_procedures

Yes No

Please describe. body.procedures.significant_procedures_detail

Have you ever been hospitalized? (Not including routine childbirth) body.procedures.has_hospitalizations

Yes No

Please describe any hospitalizations — reason and approximate date. body.procedures.hospitalization_list

Have any of these procedures or hospitalizations left lasting effects on your health or daily life? body.procedures.procedures_impact

Yes No N/A — no history

Please describe the lasting effects. body.procedures.procedures_impact_detail

Section 6

Family Medical History

Hereditary patterns and family health conditions relevant to your care.

How would you describe your access to your biological family's medical history? body.family_history.adoption_status

I have full access to my biological family's medical history I have partial access — some history, not all I have no biological family history available

Noted — That's important context. The questions below are still here in case you have any partial information worth capturing — but anything you don't know simply stays blank.

Note — We ask about conditions and patterns, not specific people. You don't need to name relatives. If you don't have this information, answer "Unknown" or leave it blank.

Is there a family history of heart disease, stroke, or high blood pressure? body.family_history.cardiovascular

Yes No Unknown

Is there a family history of cancer? If yes, please note what types if known. body.family_history.cancer

Yes No Unknown

Is there a family history of diabetes? body.family_history.diabetes

Yes — Type 1 Yes — Type 2 Yes — both/unsure No Unknown

Is there a family history of mental health conditions? (e.g. depression, anxiety, bipolar, schizophrenia) body.family_history.mental_health

Yes No Unknown

Is there a family history of autoimmune conditions? (e.g. lupus, MS, rheumatoid arthritis, thyroid disease) body.family_history.autoimmune

Yes No Unknown

Is there a family history of neurological conditions? (e.g. Parkinson's, Alzheimer's, epilepsy) body.family_history.neurological

Yes No Unknown

Any other hereditary or significant conditions that run in your family? body.family_history.other

How well do you know your family medical history? body.family_history.family_history_known

Well — I have a clear picture Partially Limitedly Not at all — mostly blank

Section 7

Systems Review

Review of all major body systems. A yes to any system will trigger a more detailed follow-up intake for that area.

Note — This is a gentle sweep. For each system, we ask if it's been relevant to your health — and whether anything is active now.

7a — Cardiovascular

Have you ever had any heart or cardiovascular issues? (e.g. heart disease, irregular heartbeat, high blood pressure, high cholesterol, blood clots) body.systems.cardiovascular.flag

Yes No

Do you currently experience any cardiovascular symptoms? (e.g. chest pain, palpitations, shortness of breath, swelling in legs) body.systems.cardiovascular.current_symptoms

Are you currently under the care of a cardiologist or cardiovascular specialist? body.systems.cardiovascular.under_cardiology_care

Yes No — managing with GP Not currently in care

7b — Neurological

Have you ever had any neurological issues? (e.g. migraines, seizures, numbness, tremors, memory issues, head injuries, stroke) body.systems.neurological.flag

Yes No

Do you currently experience any neurological symptoms? body.systems.neurological.current_symptoms

Are you currently under the care of a neurologist? body.systems.neurological.under_neurology_care

Yes No

7c — Endocrine

Have you ever had any endocrine or hormonal issues? (e.g. diabetes, thyroid disease, adrenal issues, PCOS) body.systems.endocrine.flag

Yes No

Do you currently experience any endocrine symptoms? (e.g. unexplained weight change, temperature sensitivity, unusual fatigue, excessive thirst) body.systems.endocrine.current_symptoms

Are you currently under the care of an endocrinologist? body.systems.endocrine.under_endocrine_care

Yes No

7d — Immune & Autoimmune

Do you have any immune system conditions? (e.g. autoimmune disease, frequent infections, immune deficiency, significant allergies) body.systems.immune.flag

Yes No

Do you currently experience any immune symptoms? (e.g. joint pain/swelling, skin rashes, chronic fatigue, frequent illness) body.systems.immune.current_symptoms

Are you currently under the care of a rheumatologist or immunologist? body.systems.immune.under_immunology_care

Yes No

7e — Musculoskeletal

Do you have any ongoing musculoskeletal issues? (e.g. arthritis, chronic back or joint pain, old injuries, limited mobility) body.systems.musculoskeletal.flag

Yes No

Do you currently experience musculoskeletal symptoms? body.systems.musculoskeletal.current_symptoms

Are you currently under the care of an orthopedic specialist, physical therapist, or rheumatologist? body.systems.musculoskeletal.under_ortho_care

Yes No

7f — Reproductive & Gynecological

Is there anything in your reproductive health history that is relevant to your current health picture? body.systems.reproductive.flag

Yes No N/A

Are you currently pregnant, postpartum, or going through perimenopause or menopause? body.systems.reproductive.current_status

Pregnant Postpartum Perimenopause Menopause None of these

Do you see a gynecologist or OB-GYN regularly? body.systems.reproductive.under_ob_gyn_care

Yes No

7g — Digestive & GI

Do you have any ongoing digestive or gastrointestinal issues? (e.g. IBS, Crohn's, colitis, GERD, celiac) body.systems.digestive.flag

Yes No

Do you currently experience any GI symptoms? (e.g. abdominal pain, bloating, reflux, irregular bowel habits) body.systems.digestive.current_symptoms

Are you currently under the care of a gastroenterologist? body.systems.digestive.under_gi_care

Yes No

7h — Pulmonary & Respiratory

Do you have any ongoing respiratory or lung issues? (e.g. asthma, COPD, recurring bronchitis, sleep apnea) body.systems.pulmonary.flag

Yes No

Do you currently experience any respiratory symptoms? (e.g. chronic cough, shortness of breath, wheezing) body.systems.pulmonary.current_symptoms

Are you currently under the care of a pulmonologist? body.systems.pulmonary.under_pulmonary_care

Yes No

7i — Dermatological

Do you have any ongoing skin conditions? (e.g. psoriasis, eczema, rosacea, chronic rashes, suspicious lesions) body.systems.dermatological.flag

Yes No

Are you currently under the care of a dermatologist? body.systems.dermatological.under_derm_care

Yes No

7j — Urological & Kidney

Do you have any ongoing urological or kidney issues? (e.g. kidney disease, recurring UTIs, kidney stones, bladder issues) body.systems.urological.flag

Yes No

Are you currently under the care of a urologist or nephrologist? body.systems.urological.under_urology_care

Yes No

7k — Ophthalmological

Do you have any ongoing vision or eye health issues beyond needing glasses? (e.g. glaucoma, macular degeneration, diabetic retinopathy, significant vision impairment) body.systems.ophthalmological.flag

Yes No

Do you see an ophthalmologist or eye specialist regularly? body.systems.ophthalmological.under_eye_care

Yes No

7l — ENT (Ear, Nose & Throat)

Do you have any ongoing ENT issues? (e.g. hearing loss, tinnitus, chronic sinusitis, vertigo) body.systems.ent.flag

Yes No

Are you currently under the care of an ENT specialist? body.systems.ent.under_ent_care

Yes No

7m — Other Systems

Are there any other health systems or areas we haven't covered that are relevant to your health? body.systems.other.flag

Yes No

Please describe. body.systems.other.description

Section 8

Functional Health — Pain

Pain as a functional dimension of daily life.

Note — We're not asking for a number on a scale. We're asking what pain is like to live with, if it's part of your life.

Is pain part of your daily life in any way? body.functional.pain.has_pain

Yes No — not really Occasionally

Where is the pain located? body.functional.pain.pain_location

How would you describe the pain? body.functional.pain.pain_type

Aching Sharp Burning Pressure Throbbing Mixed / hard to describe

How often do you experience pain? body.functional.pain.pain_frequency

Constant Daily Several times a week Occasional flares

How much does pain affect your ability to work, move, sleep, or engage in your life? body.functional.pain.pain_impact

Minimal Moderate Significant Severe — limits most activity

How do you manage your pain? body.functional.pain.pain_management

Are you working with any providers specifically for pain management? body.functional.pain.pain_under_care

Yes — pain specialist Through my GP Not currently

Section 9

Functional Health — Sleep

Sleep quality, patterns, and any identified sleep conditions.

How would you describe your sleep overall? body.functional.sleep.quality

Good Poor Variable OK — not great, not terrible

On average, how many hours of sleep do you get per night? body.functional.sleep.duration

Less than 4 hours 4–5 hours 5–6 hours 6–7 hours 7–8 hours 8+ hours

Do you have difficulty falling asleep? body.functional.sleep.onset

Yes — regularly Sometimes No

Do you wake during the night and have difficulty returning to sleep? body.functional.sleep.maintenance

Yes — regularly Sometimes No

Do you wake feeling rested, or tired despite sleeping? body.functional.sleep.restorative

Usually rested Mixed Often tired despite sleeping

Have you been diagnosed with any sleep conditions? (e.g. sleep apnea, insomnia, restless legs, narcolepsy) body.functional.sleep.sleep_conditions

Yes No

Please describe. body.functional.sleep.sleep_conditions_detail

How much does poor sleep affect your daily functioning? body.functional.sleep.sleep_impact

Not much — I manage Somewhat Moderately — affects my days Significantly

Section 10

Functional Health — Energy & Fatigue

Sustained energy levels as a functional health indicator.

How would you describe your energy levels overall? body.functional.energy.level

Good — I generally have enough Low — often depleted Highly variable OK — not great

Is your fatigue constant throughout the day, or does it follow a pattern? body.functional.energy.fatigue_pattern

Constant Worse in the morning Crashes in the afternoon After exertion N/A — energy is fine

Do you experience significant fatigue after physical or mental exertion that takes time to recover from? body.functional.energy.post_exertional

Yes — this is significant Sometimes No

How much does fatigue affect your ability to work, care for yourself, or do things you want to do? body.functional.energy.fatigue_impact

Not much Somewhat Moderately Significantly — limits a lot

Has a cause been identified for your fatigue? (e.g. anemia, thyroid, sleep disorder, chronic illness) body.functional.energy.known_cause

Yes No — still an open question N/A — fatigue isn't an issue

Please describe. body.functional.energy.known_cause_detail

Section 11

Functional Health — Appetite & Nutrition

Eating patterns, appetite, and nutritional wellbeing.

Note — These questions are about your general nutritional picture and access to food. We don't ask about weight or restrictive eating here.

How is your appetite generally — are you eating well, or is that an area of difficulty? body.functional.appetite.status

Good — eating well Variable Poor — appetite is low Overeating / compulsive at times Complicated — hard to answer

Have there been any significant changes in your appetite recently? body.functional.appetite.changes

No significant change Eating more than usual Eating less than usual Eating differently

Do you have consistent access to food — are you able to eat regularly without worrying about it? body.functional.appetite.food_security

Yes — reliable access Sometimes it's uncertain No — food access is a real concern

Are there dietary restrictions that affect how you eat? (Medical, religious, personal, allergies) body.functional.appetite.dietary_restrictions

Yes No

Please describe. body.functional.appetite.dietary_restrictions_detail

Does your appetite or eating significantly affect your energy, mood, or physical health? body.functional.appetite.eating_impact

Not really Somewhat Yes — noticeably

Section 12

Health Behaviors

Exercise, substance use, and other lifestyle factors relevant to health.

Note — All disclosures in this section are held without judgment. We're building a complete health picture, not evaluating your choices.

Exercise & Physical Activity

Are you physically active? Do you exercise or move your body regularly? body.functional.exercise.status

Yes — regularly Sometimes Not really

What kinds of physical activity do you do? body.functional.exercise.type

How often? body.functional.exercise.frequency

Daily 4–6 times/week 2–3 times/week Once a week or less

Are there barriers that prevent you from being as physically active as you'd like? body.functional.exercise.barriers

Substance Use

Do you smoke or use tobacco products? body.functional.substance_use.tobacco

Yes — currently Former smoker No

Do you drink alcohol? If yes, roughly how often? body.functional.substance_use.alcohol

No / rarely Occasionally — social A few times a week Daily or near-daily

Do you use cannabis? body.functional.substance_use.cannabis

Yes — regularly Occasionally No

Do you use any other recreational or non-prescribed substances? body.functional.substance_use.other

Yes No

Please describe, as much as you're comfortable sharing. body.functional.substance_use.other_detail

Do you feel your substance use affects your health or daily functioning? body.functional.substance_use.substance_impact

Not that I'm aware of Somewhat Yes — noticeably N/A — no substance use

Dependency & Recovery History

Note — These questions are about history and context — not assessment. There's no right answer. Share only what feels comfortable.

Has your relationship with any substance ever felt out of your control — something you wanted to use less of but found it hard to stop or cut back? body.functional.substance_use.dependency_history

Yes No At times — it's been complicated

Which substance or substances, if you're comfortable saying? body.functional.substance_use.dependency_substances

Is this something from your past, or something that's part of your life currently? body.functional.substance_use.dependency_timeline

Past — resolved Current Ongoing — with periods of recovery

Have you ever sought help for substance use — a program, counselor, support group, medication-assisted treatment, or anything else? body.functional.substance_use.treatment_history

Yes No Considering it

Please describe the kind of support — no names or facilities needed, just the general type. body.functional.substance_use.treatment_detail

Are you currently in recovery? body.functional.substance_use.in_recovery

Yes — currently in recovery No N/A

Do you have support in place for your recovery — people, a program, or both? body.functional.substance_use.recovery_support

Yes — good support in place Partial — some support Not really — navigating it alone

Is there anything about your recovery that's important context for us to have? body.functional.substance_use.recovery_context

Section 13

Current Providers & Care

Who is in your current healthcare picture.

Note — You don't need to include provider names or facility names — just roles and specialties.

Do you have a primary care physician or GP you see regularly? body.basics.providers.primary_care

Yes No Only when I need to

Are you currently seeing any specialists? body.basics.providers.specialists

Yes No

Please list the specialties. (No names needed.) body.basics.providers.specialist_list

Are you currently seeing a therapist, psychiatrist, counselor, or other mental health provider? body.basics.providers.mental_health_care

Yes No On a waiting list

Do you feel your current healthcare providers understand your health picture? body.basics.providers.care_satisfaction

Yes — I feel well understood Partially Not really N/A — no current providers

Are there areas of your health you feel are not currently being addressed? body.basics.providers.care_gaps

Section 14

Relationship with Body

Your subjective experience of your body — safety, trust, identity, agency.

Note — This is the most personal section of the intake. Take your time. There are no right answers here.

How do you generally feel about your body — do you feel at home in it, or is your relationship with it more complicated? body.body_relation.narrative

Is your body something you feel mostly at ease with, or does it feel like something you're at odds with? body.body_relation.comfort_with_body

Mostly at ease Mixed — it's complicated Often at odds with it I haven't thought about it much

Do you think of your body as something that works with you, or more as something that works against you? body.body_relation.body_as_ally_or_obstacle

Works with me — ally Both — depends on the day Works against me Neutral — I don't think about it

Do you generally trust your body to tell you what it needs, or does it feel more unpredictable or unreliable? body.body_relation.physical_self_trust

Yes — I trust it Mostly Often unpredictable No — I don't trust it

If health challenges have been part of your life for a long time — has that become part of how you see yourself? body.body_relation.chronic_illness_identity

Yes — it's part of my identity Somewhat Not really — I keep them separate N/A — health hasn't been a long-term challenge

Has your relationship with your body changed significantly at any point in your life? body.body_relation.body_history

Yes Not really

Please describe, if you're comfortable. body.body_relation.body_history_detail

Has illness, injury, or physical loss been a source of grief or trauma for you? body.body_relation.body_in_grief_or_trauma

Yes In some ways No

How involved do you like to be in medical decisions about your body — do you prefer to be led by your providers, or to be actively in the driver's seat? body.body_relation.body_in_care_decisions

Prefer to be led by providers Collaborative — both Prefer to be in the driver's seat Depends on the situation

✓

Intake complete.

Thank you for taking the time to complete this. Your responses have been recorded and will be used to give Charlie the context she needs to support you well.