Please complete this intake so we can better understand your goals, current lifestyle, and any areas that may be holding you back. Your answers will help us better understand your starting point and the program you selected

Which program are you interested in?

BASIC INFORMATION

Name

FirstLast

Email

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Age

Gender (Optional)

Height

Current Weight

MAIN GOALS

What are your main goals? Please choose up to 3.

What would you most like to improve about how you feel right now?

What feels most difficult for you right now?

ENERGY & SLEEP

Rate your current energy level from 1–10.

1 = Exhausted | 10 = Great Energy

When do you usually feel your lowest energy?

Rate your sleep quality from 1–10.

1 = Very Poor | 10 = Exellent

What best describes your sleep?

STRESS & MENTAL CLARITY

How would you describe your current stress level?

Are you currently experiencing any of the following? Please select all that apply.

NUTRITION & APPETITE

How would you describe your relationship with food right now?

Are hunger or cravings currently making it difficult to reach your goals?

DIGESTION & GUT HEALTH

Are you currently experiencing any of the following? Check all that apply.

MOVEMENT, TRAINING & RECOVERY

How often do you currently exercise or train?

What type of exercise or physical activity do you normally do?

How would you describe your recovery after exercise or normal physical activity?

Do you currently have an injury, joint discomfort, pain, or mobility issue that limits your activity?

Please briefly explain.

CURRENT & PREVIOUS RESEARCH

Are you currently using or researching any peptides or other research products?

Please list the products, how long you have been researching them, and the amount/frequency you arecurrently researching.

Have you used any peptides or research products in the past?

Please list what you have previously researched and approximately when.

WHAT YOU'VE ALREADY TRIED

What have you tried during the past 6-12 months? Check all that apply.

HEALTH INFORMATION

Are you currently taking any prescription medications or hormone therapies?

Please list them.

Are you currently being treated or monitored by a healthcare provider for any medical condition or health concern?

Please briefly explain.

Have you ever been diagnosed with any of the following? Please select all that apply.

Do you have a family history of medullary thyroid carcinoma or MEN2?

Are you pregnant, breastfeeding, or currently trying to conceive?

ANYTHING ELSE

Is there anything else about your health, goals, current research, lifestyle, or concerns that you think wouldbe helpful for us to know?

Research & Educational Disclaimer

VIP New Life programs are intended for educational and research purposes only and are not medical treatment or a substitute for professional medical care. Information provided through our programs is not intended to diagnose, treat, cure, or prevent any disease.

Research products offered by VIP New Life are labeled and sold for Research Use Only (RUO) and are not intended for human consumption or clinical use. Program information is provided for educational purposes. Customers should consult a licensed healthcare professional regarding personal health conditions, medications, treatments, or medical decisions.

I have read and understand the Research & Educational Disclaimer.

VIP New Life Program Intake