FOLLOW UP QUESTIONNAIRE

FOLLOW UP QUESTIONNAIRE
Name
Date

MonthDayYear
Date
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?
Are you interested in Nutrition Counseling?
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?
Have you lost weight or inches? How much? How much more do you desire to see?
What is the highest dose of Semaglutide you tried?
What supplements have you tried?

Trace MineralsSaltPeptidesOrgan SupplementsOral BPC-157KPVIodineColostrumBPC-157/TB500MagnesiumEnzymesSemaglutideB VitaminsNiacinTirzepatideVitamin DAlpha Lipoic AcidEpitalonVitamin KUltimate GI RepairGHK-CuKidneyOx BileMOD/IPAApricot SeedsBetaine HCL PepsinMelanotanVitamin CBromantaneTA1Modified Citrus PectinCoQ10MOTs-CDHEAEssential Amino AcidsBio-RegulatorsCreatineGABAIronMelatoninIntestinal Formula #1
Are you planning to start any new supplements soon? List all that apply.
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?
Should be Empty: