Health Strategy Intake

01

Basic Information

How to reach you and confirm eligibility.

First Name *

Last Name *

Date of Birth *

Sex at Birth *

Email *

Phone

State of Residence *

We're a telehealth practice currently licensed in select states. If your state isn't listed, you're welcome to submit and we'll reach out as we expand — but care can only begin once we're licensed where you live. We confirm availability before any clinical evaluation.

Street Address *

City *

Zip Code *

Height *

Weight *

Waist circumference (inches)

Measure at the navel, relaxed, end of normal exhale. If you don't have a tape handy, give your best estimate or skip.

Occupation

Baseline vitals (optional)

If you have a wearable, recent doctor visit, or home monitor, share your most recent values. Skip any you don't have handy — we'll capture them at your strategy session.

Resting heart rate (bpm)

Systolic blood pressure

Diastolic blood pressure

02

Your Health Goals & Experience

Help us understand where you are today and what you want to achieve

When was the last time you felt at your best physically and mentally?

What are the top 3 outcomes you want from working with us?

What have you tried before that didn't work or wasn't sustainable?

03

Define your top health priorities

Choose up to 3 goals that matter most to you today and rank them from highest to lowest priority (1 to 3).

Weight loss / body recomposition Energy & fatigue Mental clarity & cognition Athletic performance & recovery Sexual performance & libido Hormone optimization Longevity & healthy aging Gut health & inflammation Sleep quality

04

Readiness, Stress & Barriers

Understanding your starting point.

What kind of commitment are you looking for?

Quick reset (4-8 weeks) Multi-cycle commitment (3+ months) Long-term optimization (6+ months) Not sure yet

Does stress currently affect your health?

Yes No

Biggest stressors (check all that apply)

Work Family Sleep Financial Health anxiety Other

What could interfere with your success?

05

Medical History

Check any conditions you have been diagnosed with or are currently managing.

Metabolic / Cardiovascular

Obesity Diabetes High blood pressure High cholesterol Fatty liver Heart disease

Hormonal

Low testosterone Thyroid disorder Menopause PCOS

GI / Immune

IBS GERD / Reflux Celiac disease SIBO Autoimmune condition

Neurologic / Mental Health

Anxiety Depression ADHD Cognitive issues Migraine

Musculoskeletal

Joint pain Tendon injury Arthritis

Other diagnosed conditions (not listed above)

Have you had any major surgeries or hospitalizations? If yes, please include the procedure and approximate year.

Family history of major conditions (parents or siblings)

06

Medications & Allergies

List current prescriptions and supplements.

Are you currently taking any prescription medications? If yes, list each medication with dose and frequency.

Are you currently taking any of the following? (Check all that apply)

GLP-1 medication (Ozempic, Wegovy, Mounjaro, Zepbound, compounded semaglutide/tirzepatide) Testosterone replacement therapy (TRT) HCG Other prescribed peptides (BPC-157, TB-500, sermorelin, etc.) Supplements (vitamins, minerals, nootropics, etc.) None of the above

If you checked any boxes above, list each with name, dose, and frequency.

Drug allergies

Food sensitivities or intolerances

07

Hormones & Metabolism

How your body has been behaving.

Have you noticed weight change in the past year?

Lost weight Gained weight Stayed about the same

Where do you tend to gain weight first?

Abdomen Hips / thighs Chest Even distribution N/A

Anything else relevant about hormones, metabolism, or recent labs?

08

Gut Health

Digestion and gut function.

GI symptoms (check all that apply)

Bloating Constipation Diarrhea Reflux / heartburn Food triggers

Do certain foods trigger your symptoms? If yes, which foods?

Have you been diagnosed with any GI conditions? (e.g., IBS, GERD, SIBO, celiac, Crohn's)

Have you taken antibiotics in the past 12 months?

Yes No

Do you currently take probiotics?

Yes No

09

Brain & Mood

Cognitive and emotional health.

How would you rate your focus or mental clarity?

None Mild Moderate Severe

Do you have concerns about your memory?

None Mild Moderate Severe

If you have any focus or memory concerns, when did they start?

Acute — last 3 months, post-viral or post-event Sub-acute — 3-12 months Chronic — more than 12 months, slow progression Not applicable

Are you experiencing any of the following? (Select all that apply)

Anxiety Low mood or depression Irritability Mood swings None

Are you currently receiving support for your mental health?

No Therapy or counseling Medication Both

Family history of cognitive or neurologic conditions?

Dementia or Alzheimer's Parkinson's disease None Not sure

10

Sleep

Rest and recovery patterns.

Average hours of sleep per night

Do you wake feeling rested?

Yes Sometimes Rarely Never

Sleep disturbances (check all that apply)

Difficulty falling asleep Waking during the night Snoring or sleep apnea Restless legs None

If you checked "Snoring or sleep apnea" above, which best describes it?

Diagnosed OSA, on CPAP or alternative therapy (dental device, etc.) Diagnosed OSA, not currently treated Suspected — loud snoring or witnessed apnea, never tested Mild snoring only Not applicable / no snoring

Do you use sleep aids (prescription or OTC)?

11

Energy & Performance

Daily energy patterns.

When is your energy highest during the day?

Morning Midday Afternoon Evening No clear pattern

Daily caffeine intake

How often do you feel unusually fatigued after minimal activity?

Never Rarely Sometimes Often Daily

12

Exercise

Current activity and movement patterns.

Resistance training frequency

When you do resistance training, what intensity?

Light — comfortable, no failure sets Moderate — some sets to near-failure, no formal program Heavy — I follow a structured program, track my weights, and push close to failure regularly N/A — I don't currently lift

Cardio frequency

Sports or recreational activities

Current or recent injuries limiting exercise

Do you use any wearables or health tracking devices? (Check all that apply)

Oura Ring WHOOP Garmin Apple Watch CGM / Glucose monitor Fitbit None

Other devices or apps you use to track health/fitness

13

Peptides, Therapies & Experience

Your history with advanced therapeutics.

Have you previously used any of the following? (Check all that apply)

Nutrition coaching Supplements Hormone therapy GLP-1 or weight-loss medications Peptides None of the above

Have you previously used peptides? If so, which ones and what was your experience?

Interest level in peptide therapies

Very interested Somewhat interested Want to learn more Not interested

History with advanced therapies (IV therapy, stem cells, PRP, etc.)

14

Lifestyle, Diet & Final Notes

Eating patterns and context.

How would you describe your current diet?

Meals per day

Alcohol consumption

Tobacco / nicotine / vaping use

Never Former (quit more than 1 year ago) Occasional (social, less than weekly) Daily (cigarettes, vape, pouches, etc.)

Daily water intake

Any aesthetic concerns (skin, hair, body composition)?

What does aging well mean to you?

Is there anything important you'd like your provider to know before your visit?

You're all set.