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Nurse Consultation Intake Form

Complete this before your 1-on-1 session so our nurse can prepare the best advice for your situation.

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Section 1
About You
Basic info so our nurse can prepare for your consultation.
Full Name *
Email Address *
Phone Number *
Age *
30–39
40–49
50–59
60–69
70+
Gender *
Male
Female
Prefer not to say
Section 2
Your Circulation Symptoms
The more detail you provide, the better our nurse can help you.
In your own words, describe the circulation issues you're experiencing *
When does it happen, what does it feel like, how long has it been going on?
Which symptoms do you experience? *
Select all that apply
Cold feet or toes
Cold hands or fingers
Numbness or tingling
Leg pain or cramping when walking
Leg pain or cramping at rest
Burning or prickling sensation
Swelling in legs, ankles, or feet
Skin discoloration on legs/feet
Slow-healing wounds on legs/feet
Varicose or spider veins
Erectile dysfunction
Fatigue or heaviness in legs
Where do you feel symptoms most? *
Feet / toes
Lower legs / calves
Upper legs / thighs
Hands / fingers
All over
How long have you been experiencing these symptoms? *
Less than 3 months
3–6 months
6–12 months
1–3 years
3–5 years
5+ years
On a scale of 1–10, how much do your symptoms affect your daily life? *
Not at allSeverely
Do your symptoms wake you up at night? *
Yes, almost every night
Yes, a few times a week
Occasionally
Rarely or never
Section 3
Medical Background
This helps our nurse prepare. All information is confidential.
Have you been diagnosed with any of the following? *
Select all that apply
Peripheral artery disease (PAD)
Type 2 diabetes
High blood pressure
High cholesterol
Raynaud's disease
Deep vein thrombosis (DVT)
Heart disease
Neuropathy
None of the above
Are you currently taking any medications? *
If yes, please list them. If no, write "None".
Does poor circulation run in your family?
Yes
No
Not sure
Has your doctor ever mentioned concerns about your circulation?
Yes — and recommended treatment
Yes — but no treatment was offered
No
I haven't seen a doctor about this
Section 4
What You've Already Tried
Understanding what hasn't worked helps us avoid wasting your time.
What have you tried to improve your circulation? *
Select all that apply
Compression socks or stockings
Topical creams or ointments
Prescription medications
Over-the-counter supplements
Massage or physical therapy
Exercise or walking routine
Warm baths or soaking
Elevation / propping up legs
Diet changes
Nothing yet — this is my first step
If you've tried supplements before, which ones?
Brand names, ingredients, anything you remember
What was your experience with things you've tried? *
What worked, what didn't, what was frustrating?
What's been the MOST frustrating part of dealing with your circulation issues? *
Section 5
Your Goals
Help us understand what matters most to you.
What would "success" look like for you? *
What's the #1 thing you want to change about your circulation?
What activities or moments does poor circulation affect most? *
E.g., sleeping, walking, standing at work, playing with grandkids…
Are you looking for a natural approach? *
Strongly prefer natural / no pharmaceuticals
Prefer natural, but open to prescriptions if needed
Open to anything that works
I'm on prescriptions and looking for natural alternatives
How quickly do you need to see results?
I need relief as soon as possible
Within a few weeks would be great
I'm willing to be patient for the right solution
I just want to stop things from getting worse
Section 6
How Did You Hear About Us?
How did you first find out about GetJacked? *
Facebook or Instagram ad
Google search
YouTube
A friend or family member recommended it
Online health article or blog
Reddit or online forum
My doctor or healthcare provider
What made you decide to book a consultation? *
What pushed you over the edge to take action?
Are you currently a GetJacked customer? *
Yes — I'm currently taking the capsules
I've ordered but haven't started yet
I used to take them but stopped
No — I'm considering it
No — I just want the consultation
If you're a current customer, how long have you been taking GetJacked?
Less than 1 month
1–3 months
3–6 months
6+ months
N/A — not a customer
Section 7
Lifestyle & Final Questions
How would you describe your daily activity level?
Mostly sedentary (desk job, lots of sitting)
Lightly active (some walking)
Moderately active (on feet regularly)
Very active (physical job or regular exercise)
Limited — my symptoms restrict my movement
Do you smoke or use tobacco products?
Yes, currently
I used to but quit
No, never
Monthly spend on circulation-related products/treatments?
$0 — I haven't spent anything
Under $25/month
$25–$50/month
$50–$100/month
$100+/month
What questions do you want to ask the nurse?
This helps us prepare so we can make the most of your time
Anything else you'd like us to know?
Preferred consultation time *
Morning (9am–12pm EST)
Afternoon (12pm–4pm EST)
Evening (4pm–7pm EST)
I'm flexible
How would you prefer the consultation? *
Phone call
Video call (Zoom)
No preference
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You're all set!

Your consultation intake has been submitted successfully. Our nurse will contact you as soon as possible to find a suitable time for your session.

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