Your answers help us understand where you are today so we canguide you toward feeling, performing, and living at your best.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Email
*
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Occupation
Current Weight
Goal Weight
Current Activity Level
Low
Moderate
High
Other
Your Top Priorities
1.In the next 6–12 months, what are your top 3 outcomes?(check up to 3)
2.How important is it for you to improve your health and energyright now?
Not at all
Slighty
Neutral
Important
Very Important
Weight, Cravings & Metabolism
3.How important is it for you to improve your health and energyright now?
Not at all
Slightly
Moderately
Significantly
Severely
4.How often do you feel like your weight or midsection isslowly creeping up, even when you’re trying?
Never
Rarely
Sometimes
Often
Always
5.How much do you struggle with (overall): •Constant thoughts about food / “food noise” •Nighttime snacking •Overeating on weekends or social events
Not at all
Slightly
Moderately
Significantly
Severely
6.Have you ever lost weight and then regained it within thelast 2–3 years?
No
Yes, 5–10 lbs
Yes, 10–25 lbs
Yes, 25+ lbs
7.Have you used GLP-1 medications (like semaglutide ortirzepatide) before?
No
Yes – and I did well
Yes – but I had side effects
Yes – lost weight but gained most of it back
Energy, Focus & Mood
8.Do you experience chronic fatigue, low stamina, or frequent“energy crashes”?
Never
Rarely
Sometimes
Often
Always
9.How often do you struggle with brain fog, poor focus, orforgetfulness?
Never
Rarely
Sometimes
Often
Always
10.How often do you feel stressed, overwhelmed, or mentallyburned out?
Never
Rarely
Sometimes
Often
Always
Recovery, Pain & Inflammation
11.“I recover slower than I should from workouts, soreness, orinjuries.
Not at all
Slightly
Moderately
Significantly
Severely
12.Do you deal with chronic joint or tendon pain that limits yourtraining or daily activity?
Never
Rarely
Sometimes
Often
Always
13.Have you had lingering discomfort from an old injury orsurgery?
No
Yes – mild
Yes – moderate
Yes – significant
Sleep, Immune & Detox
14.How often do you struggle with poor sleep, frequentwaking, or unrefreshing sleep?
Never
Rarely
Sometimes
Often
Always
15.Do you feel like you get sick easily or take a long time tobounce back from illness?
Never
Rarely
Sometimes
Often
Always
16.Are you regularly exposed to alcohol, smoking, travel, orenvironmental toxins (chemicals, pollution, etc.)?
Never
Rarely
Sometimes
Often
Always
Healthy Aging, Appearance &Longevity
17.How concerned are you about aging-related changes(strength, stamina, body composition)?
Not Concernced
Slightly
Neutral
Concerned
Very Concerned
18.How much do you notice things like dull skin, fine lines,thinning hair, or slower healing?
Not at all
Slightly
Moderately
Significantly
Severely
19.How interested are you in programs focused on longevityand aging well (not just quick fixes)?
Not Interested
Somewhat Interested
Very Interested
Extremely Interested
Microdosing Fit Check
20.Which best describes your current weight situation?
I want to lose 20+ lbs
I want to lose 10–20 lbs
I am close to my goal weight but fighting slow weight gain or “menopause belly”
My main goal is not big weight loss – I care more about control,consistency, and how I feel
21.How often do you feel like your habits are mostly good,but hormones, stress, or age are still pushing yourweight, cravings, or blood sugar in the wrongdirection?
Never
Rarely
Sometimes
Often
Always
22.Which of these sound like you? (check all that apply)
I want gentle appetite and craving control without a high-dose protocol
I’m worried about nausea or side effects from full-dose GLP-1medications
I’ve done a GLP-1 program and want to maintain results on a lighter plan
I have blood sugar / insulin resistance concerns and want extra supportstaying stable
I’m dealing with inflammation, aches, or“puffy”weight tied to sess or hormones
I’m in perimenopause or menopause and notice stubborn midsection gainand cravings
I’m in a high-stress, travel, or event-heavy season and need help stayingconsistent
High-Level Medical History
23.Have you ever been told by a doctor that you shouldnot take GLP-1 medications (Ozempic, Wegovy,Mounjaro, Zepbound, etc.)?
No
Yes
Why?
24.Have you ever been diagnosed with any of thefollowing? (check all that apply)
Diabetes
Uncontrolled Type 2 diabetes
History of pancreatitis
History of medullary thyroid cancer or MEN2
Severe GI disease (gastroparesis, severe Crohn’s, etc.)
Active cancer treatment
None of the above / not sure
25.Are you currently:
Pregnant
Breastfeeding
Planning pregnancy in the next 6 months
None of the above
High-Level Medical History Cont.
26.Major current health conditions or concerns you think themedical provider should know about:
27.Current prescription medications or major supplements:
Submit
Should be Empty: