FOLLOW UP QUESTIONNAIRE

FOLLOW UP QUESTIONNAIRE
Name
Date

MonthDayYear
Date
Email
example@example.com
What is your typical diet? (Foods you generally eat in an average 48 hour period)
Breakfast?
Lunch?
Dinner?
Snacks?
Has your diet changed?
What do you still want to implement in your diet?
Has the variety of foods you eat improved?
Do you think you are staying adequately hydrated?
Getting enough electrolytes?
Have you changed the kinds of liquids you drink? If so, how and what?
Have your food sensitivities gotten better?
Has your skin health changed?
Has your sleep changed?
Any Injuries since your last visit?
Has your cognitive function improved?
How are your Allergies?
Libido?
How is your gut health?
Alcohol consumption?
Bowel Movements?
Depression or Anxiety?
Have you been sick this year?
Please give details about any questions above that you would like to discuss further.
Have you lost weight or inches? How much? How much more do you desire to see?
If you have used a weight loss peptide, what is the highest dose you reached?
Are you planning to start any new supplements soon? List all that apply.
What medications are you using?
Are you taking bioidentical hormones?
What is the biggest barrier to reach your goals?
What guidance do you want from us?
Anything else that is pertinent and you want to share?
What supplements have you tried?

Trace MineralsPotassium/ElectrolytesOrgan SupplementsIodineColostrumMagnesiumEnzymesB VitaminsNiacinAlpha Lipoic AcidVitamin KKidneyOx BileApricot SeedsBetaine HCL PepsinVitamin CBromantaneModified Citrus PectinCoQ10DHEAEssential Amino AcidsCreatineGABAIntestinal Formula #1CopperOral BPC-157SeleniumMSM SulphurBaking SodaIvermectinMethylene BlueZeoliteDiatomaceous EarthZincBoronChromiumFatty 15 Omega 3Allulose SugarTurpentineLiver CleanseHydrogen WaterMelatonin
What peptides have you tried

KPVBPC-157TB500SemaglutideTirzepatideRetatrutideCerebrolysinSS-31MOTs-CBioRegulatorsGHK-CuMOD GRFIpamorelinTA1PT-141EpitalonMelanotan 1Melanotan 2Tesamorelin
Should be Empty: