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)
Weight loss / metabolism
Energy & fatigue
Hormone balance
Anti-aging / longevity
Muscle recovery / performance
General wellness
Other (add short text field)
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
None
Other
7
Please list all current medications, supplements, or ongoing treatments.* This field is required.(If no medications type "NONE")
Huge
Large
Normal
Small
Ok
Ok
8
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
9
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)
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
Kidney disease (moderate to severe)
Liver disease
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)
None of the above
10
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 hours with your next steps. If you are eligible, this will include completing your full medical intake and moving 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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