Advanced Weight Management Intake Form
This comprehensive intake allows our team to design the most precise, sustainable, and results-driven weight management protocol tailored specifically to you. Please answer honestly and thoroughly.
Personal Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Birthdate
*
Month / Day / Year
Height
*
Current Weright
*
Goal Weight
*
Lifestyle & Schedule
Occupation
*
Typical Work Hours
*
Commute Time (if applicable)
*
Current Stress Level (1-10)
*
Daily Step Count (if known)
*
Sleep & Recovery
Average Bedtime
*
Average Wake Time
*
Total Hours of Sleep
*
Sleep Quality (Poor / Fair / Good / Excellent)
*
Do you nap? If yes, how often?
*
Training & Physical Activity
Gym Access (Yes / No / Home Gym)
*
Training Start Time
*
Training Duration
*
Training Frequency (days / week)
*
Current Training Style (Strength, Hypertrophy, Cardio, Hybrid)
*
Injuries or Movement Limitations
*
Nutrition & Eating Habits
Number of Meals per Day
*
Typical Meal Times
*
Food Preferences
*
Food Allergies or Intolerances
*
Water Intake (oz/day)
*
Alcohol Intake (frequency)
*
Weight History
Highest Adult Weight
*
Lowest Adult Weight
*
Recent Weight Changes (last 6 months)
*
Past Diets or Programs Tried
*
What has worked / not worked?
*
Medical & Health Background
Current Medications
*
Supplements Currently Used
*
Diagnosed Medical Conditions
*
History of Metabolic, Hormonal, or Cardiovascular Issues
*
Physician Clearance to Exercise (Yes / No)
*
GLP-1 / Peptide / Enhancement Use (If Applicable)Current or Past GLP-1 Use
Current or Past GLP-1 Use
*
Peptides or Performance Enhancers Used
*
Side Effects Experienced
*
Primary Goal for Use
*
Goals & Expectations
Primary Goal (Fat Loss / Recomp / Health / Performance)
*
Secondary Goals
*
Timeline Expectations
*
Biggest Obstacles
*
Non-Negotiables (schedule, food, lifestyle)
*
Submit
Should be Empty: