Assessment Form

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Year
Month
Day
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Please enter a valid phone number.
5
What are you primarily looking to improve or optimize?* This field is required.(Select all that apply)
Fertility & Reproductive Health
Cognitive Function
Pain Relief & Recovery
Immune Support
Longevity & Anti-Aging
Weight loss / metabolism
Energy & fatigue
Hormone balance
Muscle recovery / performance
General wellness
Other
6
What challenges or symptoms are you currently experiencing?* This field is required.(Select all that apply)
Difficulty losing weight
Low energy
Poor sleep
Brain fog
Hormonal imbalance
Pain / inflammation
Slow recovery
Digestive issues
Constant fatigue or low energy
Brain fog, poor focus, or memory slips
Stubborn weight gain or slow metabolism
Joint pain, stiffness, or slow injury healing
Low libido, mood swings, or sleep issues
Frequent sickness or slow recovery from colds
Other
None
Other
7
What challenges or symptoms are you currently experiencing?* This field is required.(Select all that apply)
Difficulty losing weight
Low energy
Poor sleep
Brain fog
Hormonal imbalance
Pain / inflammation
Slow recovery
Digestive issues
Constant fatigue or low energy
Brain fog, poor focus, or memory slips
Stubborn weight gain or slow metabolism
Joint pain, stiffness, or slow injury healing
Low libido, mood swings, or sleep issues
Frequent sickness or slow recovery from colds
Other
None
Other
8
Have you ever been diagnosed with, or are you currently managing, any of the following? (Select all that apply)* This field is required.
Active cancer or history of cancer
Autoimmune condition (e.g., MS, Lupus, Rheumatoid Arthritis)
History of blood clots, stroke, or deep vein thrombosis (DVT)
Severe kidney or liver disease
Currently pregnant or breastfeeding
None of the above
9
Important Clinical Note: Thank you for sharing this information. Because conditions like cancer, MS, and other complex illnesses heavily impact immune and cellular function, certain therapies (such as specific peptides or regenerative treatments) may require strict medical clearance or modification. Our medical director will carefully review your history during your consultation to prioritize your safety and coordinate safely with your primary oncology or neurology teams.
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Please list all current medications, supplements, or ongoing treatments.* This field is required.(If no medications type "NONE")
Huge
Large
Normal
Small
Ok
Ok
11
Are you open to a personalized, physician-guided program if recommended for you?* This field is required.
Yes
Maybe / I want more information
Not sure yet
12
For your safety, please let us know if any of the following apply to you:* This field is required.(Check all that apply. Make sure to scroll down)
Currently pregnant or trying to become pregnant
Currently breastfeeding
Personal history of medullary thyroid cancer (MTC)
Family history of medullary thyroid cancer (MTC)
Multiple Endocrine Neoplasia syndrome type 2 (MEN2)
Active cancer (currently undergoing treatment), or History of cancer
Recent cancer diagnosis (within the past 5 years)
History of severe allergic reaction to injectable medications
Severe gastrointestinal disease (including gastroparesis)
History of pancreatitis
Uncontrolled diabetes or severe insulin resistance
Kidney disease (moderate to severe)
Liver disease (moderate to severe)
Significant cardiovascular disease (such as recent heart attack, stroke, or unstable heart condition)
History of gallbladder disease or gallstones
History of hormone-sensitive cancer (e.g., breast, prostate)
Prostate issues or elevated PSA (for male patients)
Unexplained shortness of breath or chest pain
None of the above
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Medical Disclaimer: This quiz is the first step in our pre-qualification process for our wellness, metabolic, and regenerative therapies (including weight loss, HRT, peptide, and cellular programs). It does not provide medical advice, diagnosis, or treatment. Completing this assessment does not establish a provider-patient relationship. Our telemedicine team will review your responses and contact you regarding your eligibility and next steps.
14
Thank you for completing your assessment.

This step helps us better understand your goals and identify any factors that may influence your eligibility.

You can expect an email within 24-48 hours with your next steps. We will review this assessment and email you with the next steps on how to move forward with a personalized consultation.

These steps are designed to ensure that your care is safe, appropriate, and tailored specifically to you.

We look forward to supporting your care.
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By signing below, I certify that I am at least 18 years of age and that all information provided in this quiz is true, accurate, and complete to the best of my knowledge. I understand that providing false or misleading information could impact my safety and potential treatment options.
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Signature* This field is required.
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Date* This field is required.
Date
Month
Day
Year
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