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 *

Height

Weight

Occupation

02

Goals & Context

Help us understand your health narrative.

When was the last time you felt truly well?

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

In 6 months, how would you know this program was a success?

What has not worked for you in the past?

03

Primary Health Goals

Choose up 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

Top Priority Goal

Which ONE goal matters most right now?

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

05

Readiness, Stress & Barriers

Understanding your starting point.

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?

06

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 diagnoses not listed above

Major surgeries or hospitalizations

Relevant family history (heart disease, cancer, diabetes, etc.)

07

Medications & Allergies

List current prescriptions and supplements.

Current medications (name, dose, frequency)

Current supplements or peptides

Drug allergies

Food sensitivities or intolerances

08

Hormones & Metabolism

How your body has been behaving.

Have you noticed weight change in the past year?

Gained Lost Stable Not sure

Where do you tend to carry extra weight?

Abdomen Hips / thighs Chest Even distribution N/A

Any additional notes on hormonal or metabolic concerns

09

Gut Health

Digestion and gut function.

GI symptoms (check all that apply)

Bloating Constipation Diarrhea Reflux / heartburn Food triggers

Have you been diagnosed with a GI condition?

Antibiotics in the past 6 months?

Yes No

Do you currently take probiotics?

Yes No

10

Brain & Mood

Cognitive and emotional health.

How would you rate your brain fog?

None Mild Moderate Severe

Any memory or concentration concerns?

Current mood concerns (anxiety, depression, irritability, etc.)

Are you currently in therapy or counseling?

Yes No

Family history of neurodegenerative disease?

Yes No Not sure

11

Sleep

Rest and recovery patterns.

Average hours of sleep per night

Do you feel rested when you wake up?

Yes Sometimes Rarely Never

Sleep disturbances (check all that apply)

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

Do you use sleep aids (prescription or OTC)?

12

Energy & Performance

Daily energy patterns.

When is your energy highest during the day?

Morning Midday Afternoon Evening No clear pattern

Daily caffeine intake

Do you experience unusual fatigue with exertion?

Yes No

13

Exercise

Current activity and movement patterns.

Resistance training frequency

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

14

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.)

15

Lifestyle, Diet & Final Notes

Eating patterns and context.

How would you describe your current diet?

Meals per day

Alcohol consumption

Daily water intake

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

What does aging well mean to you?

Anything else you'd like us to know?

You're all set.