Personalized Wellness Assessment
Answer a few quick questions to determine your personal wellness score and eligbility. This is an informational screening only.
Energy and Recovery
How would you rate your daily energy level?
*
Excellent
Good
Fair
Poor
Very Poor
How well do you sleep most nights?
*
Excellent (7-9 hours)
Good
Fair
Poor
Very Poor
How often do you experience brain fog, forgetfulness, or difficulty concentrating?
*
Never
Rarely
Sometimes
Often
Daily
How often do you wake up feeling refreshed and ready for the day?
*
Every Day
Most Days
Sometimes
Rarely
Never
Weight & Metabolic Health
How satisfied are you with your current weight?
*
Very satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Very dissatisfied
How difficult is it for you to lose weight?
*
Very easy
Somewhat easy
Moderately difficult
Very Difficult
Nearly impossible
How often do you experience cravings for sweets or carbohydrates?
*
Never
Rarely
Sometimes
Often
Multiple times per day
How often do you exercise intentionally (walking, strength training, cardio, sports, etc.)?
5-7 days per week
3-4 days per week
1-2 days per week
A few times per month
Rarely or never
Hormone Health
Have you noticed changes in your hormones over the past few years? (select all that apply)
*
Low sex drive
Low testosterone
Menopause / perimenopause symptoms
Irregular menstrual cycles
Erectile dysfunction
Fatigue
Mood changes
Night sweats
Hot flashes
Reduced muscle mass
None of the above
How often do you feel tired even after getting a full night's sleep?
*
Never
Rarely
Sometimes
Often
Almost every day
Have you noticed a decline in your muscle strength, endurance, or physical performance?
*
No
Slightly
Moderately
Significantly
Unsure
Mental Wellness
How would you rate your current stress level?
*
Very low
Mild
Moderate
High
Extremely High
How would you describe your overall mood over the past month?
*
Excellent
Good
Fair
Poor
Very Poor
During the past month, how often have you felt anxious, overwhelmed, or emotionally exhausted?
*
Never
Rarely
Sometimes
Often
Nearly every day
Lifestyle and Nutrition
How would you rate your overall nutrition?
*
Excellent
Good
Fair
Poor
Very poor
Approximately how much water do you drink per day?
*
More than 80 oz
60-80 oz
40-60 oz
20-40 oz
Less than 20 oz
Which symptoms are affecting your quality of life? (select all that apply)
*
Fatigue
Weight gain
Brain fog
Poor sleep
Anxiety
Depression
Low motivation
Low libido
Hair thinning
Joint pain
Chronic inflammation
Digestive issues
Frequent headaches
Reduced muscle strength
Difficult recovering after exercise
None of the above
Recover & Longevity
Which wellness goals are most important to you? (Select up to 3)
*
Lose weight
Improve energy
Better sleep
Hormone optimization
Reduce stress
Improve mood
Increase muscle mass
Improve athletic performance
Recover faster after exercise
Healthy aging
Better focus and memory
Improve immune health
Reduce inflammation
Increase longevity
Improve sexual wellness
Which services are you most interested in learning more about?
*
Medical weight loss
Hormone replacement therapy
Mental health services
Peptide therapy
Longevity & health aging
Nutrition counseling
Comprehensive lab testing
Mens health and wellness
Womens health and wellness
Preventative care
Skin & hair restoration
Wellness Score
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
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