Personalize Wellness Form

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Personalized Metabolic & Wellness Review

Let’s Find Your Best Next Step-
Name*

First NameLast Name
Email*
example@example.com
Age*
Weight*
Height*
Biological Sex*

FemaleMale
BMI Calculator*
Goal Weight
Weight and Nutrition History
Do you currently follow any particular kind of diet?*

No real diet- If I want it, I eat itI don't have a certain diet, but I am mindful and try to make healthy choicesKetoVegan/VegetarianIntermittent fastingCalorie-restricted dietOther
How successful have you been with your current eating plan?*

Very successful and I feel like I am doing well!I am trying but it feels hard at timesDiets are hard for me to follow for more than a couple of days/weeksI have completely given up
Health History
Have you been diagnosed with Diabetes Type 1 or Type 2*

I have Diabetes Type 1I have Diabetes Type 2I have pre-diabetesNone of the above
What description best fits your current hormone status?

Still have regular menstrual periods.Total hysterectomy- no ovaries or uterus.Partial hysterectomy- no uterus but I still have one or both ovaries.I still have all my female organs, but I haven't had menstrual period in over a year.I still have all my female organs but my periods have gotten irregular past age 40.I am younger than 40 but my periods are very irregular
Are you currently on female hormone replacement therapy?

YesNoI can not be on HRT because of a medical reasonI tried HRT in the past and did not do well with it
Are you on male hormone replacement therapy?

YesNoNo, I don't qualify because of a medical conditionI tried HRT in the past and did not do well with it
When did you last have bloodwork done?*

Within the last 3 months3-6 months agoWithin the last year1-2 years agoGreater than 2 years ago
Do you drink alcohol?*

YesNo
How much alcohol do you drink?

Less than 1 drink a weekI only drink on the weekends, even then it only a few drinks1 drink a day or less2 or more drinks a day
How would you describe your current level of physical activity?*

Mostly sedentaryLight activity (walking, daily movement)Regular activity (exercise 4+ days/week)Athlete
GLP1 Medicine Experience
Are you currently using a GLP-1 medication?*

YesNoI have been on one in the past
Which GLP1 medicine are you currently taking and what dose? *
Which GLP1 medicine have you taken in the past?*
Do you currently have insurance coverage for GLP1s?*
If you are taking a GLP1, how long have you been on the medication?*
Who is your GLP1 provider currently?*
Are you currently experiencing any unwanted side effects of GLP1s?*

NauseaAbdominal PainDiarrheaConstipationHair sheddingDifficulty eating enoughHeadachesOther
What is your total monthly cost of GLP1 therapy?*
What made you discontinue GLP1 therapy?*

CostUnwanted side effectsLost access to medsScared about taking medsOther
Are you afraid of injections?*

Not at allDon't love the idea, but I could probably do itVery unsure about giving myself an injectionNo way I could do an injection
Current Concerns
Are you currently experiencing any of the following?*

Fatigue or low energyBrain fogDifficulty managing weightInsomnia or sleep issuesInflammation or joint painLoss of muscle massDecreased sex drive or low libidoMood swingsRapidly aging skinStubborn belly fat or midsectionWeight loss plateaus
Is there anything that still feels unresolved with your health or weight?
What feels the most overwhelming right now?

Not knowing where to startToo many online optionsFear of side effectsCost concerns
What kind of support do you like best?*

I need very clear step-by-step guidanceI like to be checked on once in a while, but too much is overwhelmingI am self-directed and I mostly want to do things myself
Privacy & Important Information

Please review before submitting
Submission of this form does not constitute a guarantee of services or follow-up. Reviews are conducted on a first-come, first-served basis and are subject to availability.

Personalized wellness feedback may vary based on individual information provided and circumstances.

All information provided in this form is submitted voluntarily and will be handled in a confidential manner. Reasonable administrative and technical safeguards are used to protect the information you share.

This intake is designed for a personal, non-clinical review of overall metabolic wellness and general educational guidance only. It is not intended to provide medical advice, diagnosis, or treatment, and submission of this form does not establish a patient-provider relationship.

You should always consult your own licensed healthcare provider regarding medical decisions, medications, or treatment plans.

By submitting this form, you acknowledge and agree to the terms above.
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Form

Personalized Metabolic & Wellness Review

Weight and Nutrition History

Health History

GLP1 Medicine Experience

Current Concerns

Privacy & Important Information