Health Assessment

Health Assessment

Real people. Real results. Real science.
Thank you for your interest in our program.

I’m excited to learn more about your goals and help you create a plan to achieve your health goals.

This will take just 2 minutes. Your answers help me tailor your plan to fit your lifestyle perfectly.
Full Name

First NameLast Name
What are your top 2–3 health goals right now? (e.g., Fat loss, energy, hormonal balance, metabolic reset, better eating habits)
How long have you been struggling with this?
Have you been diagnosed with or currently managing any of the following?
Are you currently taking any prescription medications, supplements, or weight-loss medications (including GLP-1s like Ozempic, Wegovy, etc.)?
On a scale of 1–10, How would you describe your daily energy?(1 = I’m exhausted all the time; 10 = I wake up energized and ready to go)

1

2

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9

10

1 is 1 (Very inconsistent), 10 is 10 (Very consistent)
On a scale of 1–10, How would you rate your sleep quality?(1 = Terrible; 10 = Rested and consistent)

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2

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5

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10

1 is 1 (Very inconsistent), 10 is 10 (Very consistent)
On a scale of 1–10, How would you describe your stress level most days?(1 = Calm; 10 = Overwhelmed)

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10

1 is 1 (Very inconsistent), 10 is 10 (Very consistent)
Do you experience any of these?(Checkboxes — select all that apply)
What does a normal day of eating look like for you?
What’s motivating you to improve your health right now?
What would it mean for you to feel healthy, confident, and energized again?
Who referred you or how did you find me?
Best phone number for our call:
Please enter a valid phone number.Format: (000) 000-0000.
What’s the best time for our call?
Email Address
example@example.com
City / State
Should be Empty: