Wellness & Metabolic Program Review
Part 1. Basic information
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Gender
Male
Female
Age
*
years
Height
in
Weight
lbs.
Part 2. Primary Health Context
What best describes your current situation? (Select all that apply)
*
I have metabolic health concerns (blood sugar, insulin resistance, cholesterol, blood pressure)
I am currently using GLP-1 medication
I have used a GLP-1 medication in the past
I have had gastric sleeve or bariatric surgery
I am seeking preventative metabolic support
I am unsure and want professional guidance
Part 3. GLP-1 & Surgery Screen
If GLP-1 - Are you currently taking GLP-1 medication?
*
Yes
No
If yes, how long have you been on medication?
Please Select
Less than 3 months
3-6 months
6-12 months
Over 12 months
What are you hoping to improve? (Select all that apply)
Energy
Nutrition adequacy
Muscle preservation
Side effect management
Long-term sustainability
If BARIATRIC; Have you had bariatric surgery?
Please Select
Gastric sleeve
Gastric Bypass
Other
Prefer not to say
Part 4. About Your Current Support
About Your Current Support
Are you currently working with a provider for nutrition or metabolic health?
*
Yes
No
How ready are you for structured guidance and follow-through?
*
Just exploring
Somewhat ready
Fully comitted
Part 5. HSA/FSA Information
About Your Current Support
I currently have:
*
HSA
FSA
Not sure
Neither
Neither, but I still want to participate
I UNDERSTAND THAT HSA/FSA ELIBILITY IS DETERMINED BY MY PLAN ADMINISTRATOR AND THAT A LETTER OF MEDICAL NECESSITY MAY BE REQUIRED FOR FSA USE
*
Yes
Part 6. Goals & Concerns
In your own words, what are you hoping to gain from metabolic or GLP-1 support?
*
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