AXIS WELLNESS Intake Form

AXIS WELLNESS Intake Form

Please provide accurate information to help tailor your consultation. This form is for educational and research purposes only, not medical advice.
Full Name*

First NameLast Name
Age*
Height (please specify units)*
Weight (please specify units)*
Body Fat % (If known)
Location (City, State, Country)*
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Primary ObjectiveWhat is your main goal right now?*
Is there any secondary goals aside from your Primary Objective? (E.g Lose 5lbs, increase lean muscle 3lbs, decrease inflammation, Increase energy, Cognitive performance, sleep, etc)*
Current Health StatusList any diagnosed medical conditions, autoimmune conditions, cancer history, cardiovascular issues, neurological conditions or any eating disorders.*
Current Medications & Hormones TRT/HRT (dose/frequency), prescriptions, peptides, GLP-1 use.*
Recent BloodworkHave you had bloodwork in the last 6 months? Include CBC, CMP, Lipids, Glucose/Insulin/HbA1c, Hormones, Thyroid. (If available, please attach or send through to EvanTcoaching@Gmail.com )*
File Upload

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Lifestyle Overview

Share your current habits and routines.
Training Frequency (days per week)*
Type of Training
Training Intensity Level out of 10 (1=Very Easy > 10=All out Hard as possible)

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Average Daily Steps*
Daily Hydration (liters or oz)*
Sleep Average (hours per night)*
Stress Level (1–10)*

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Alcohol Intake (per week)*
Smoking or Recreational Drug Use (Judge Free Zone)*
Peptide Experience (Give as much detail if used) Previous peptides used, duration, side effects or reactions.*
What do you know about Peptide Therapy? (if any)*
Sensitivities & Reactions Histamine reactions, allergies, injection sensitivity.*
Commitment Are you willing to implement necessary lifestyle changes?*
Any other notes or questions you'd like to share?*
For educational and research purposes only, this is not medical advice. Always consult with your healthcare provider.
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AXIS WELLNESS Intake Form

Lifestyle Overview