Step 1 of 2: Patient Assessment
Patient Information
First Name
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Last Name
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Date of birth
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Age
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Occupation
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Current Weight
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Goal Weight
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Current Activity Level
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Low - I have a sedentary job and don't move much
Moderate - I am fairly active
High - I am a very active person
Your Health Goals
Do you feel your habits are mostly good, but hormones, stress, or age are still affecting your weight and cravings?
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Yes
No - I don't feel that hormones, stress, or age are affecting my weight
Which of the following applies to you? Check all that apply.
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I want gentle appetite and craving control without high-dose medication
I am concerned about nausea or side effects from full-dose GLP-1 medications
I previously used GLP-1 therapy and want a maintenance plan
I want help stabilizing blood sugar or insulin resistance
I deal with inflammation, bloating, or stress-related weight gain
I am in perimenopause or menopause and noticing stubborn weight gain
My lifestyle involves travel, stress, or irregular routines
In the next 6-12 months, what outcomes matter most to you?
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Lose 10-20 pounds
Lose 20+ pounds
Maintain weight/stop gradual weight gain
Reduce cravings or emotional/late-night eating
Increase daily energy and focus
Improve workout recovery or injury recovery
Improve sleep quality
Strengthen immune health
Improve skin, hair, or overall appearance
Support health aging/longevity
Weight, Metabolism & Cravings
Do you feel your weight or midsection slowly increases even when eating relatively healthy?
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Yes
No
Do you struggle with food cravings or appetite control?
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Yes
No
Have you lost weight and regained it within the last 2-3 years?
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Yes
No
Have you used GLP-1 medications before (Semaglutide, Trizepatide, Ozempic, Wegovy, Mounjaro, Zepbound, etc.)?
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Yes
No
If yes, please describe your experience:
Energy, Stress & Cognitive Health
Do you experience frequent fatigue or energy crashes?
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Yes - constantly
Sometimes
No
Do you struggle with brain fog, poor focus, or forgetfulness?
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Yes - constantly
Sometimes
No
Do you often feel stressed, overwhelmed, or mentally burnt out?
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Yes - constantly
Sometimes
No
Recovery, Pain & Inflammation
Does it feel like you recover slowly from workouts or physical activity?
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Yes
No
Do you experience pain in your joints, tendons, or feel inflamed?
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Yes - often
Sometimes
No
Do you have lingering discomfort from a past injury or surgery?
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Yes
No
Sleep, Immunity & Lifestyle
Do you struggle with poor sleep or waking up feeling unrefreshed?
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Yes - often
Sometimes
No
Do you tend to get sick easily or take longer to recover from illness?
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Yes
No
Are you regularly exposed to any of the following? Check all that apply.
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Frequent alcohol use
Smoking / nicotine
Frequent travel
Environmental toxins / chemicals
Overall high stress (lifestyle)
Hormones, Aging & Longevity
Are you concerned about changes related to aging such as strength loss, body composition changes, or stamina?
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Yes - very much so
A little bit
No
Are you noticing changes in skin quality, hair thinning, or slower healing?
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Yes
No
Are you interested in a wellness plan focused on longevity and aging well, not just weight loss?
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Yes
No, just weight loss
Medical History
Have you ever been told by a physician not to take GLP-1 medication?
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No
Yes
If yes, please explain:
Have you ever been diagnosed with any of the following? Check all that apply.
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Type 1 Diabetes
Uncontrolled Type 2 Diabetes
Pancreatitis
Medullary thyroid cancer or MEN2
Severe GI disease (gastroparesis, Chron's, ulcerative colitis, etc.)
Active cancer treatment
None of the above
Are you currently:
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Pregnant
Breastfeeding
Planning pregnancy within the next 6 months
Additional Medical Information
Please list any major health concerns your provider should know about:
Please list all of your current medications, their dosage, and frequency:
Do you have any medication allergies?
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No
Yes
If yes, please list which medication and associated reaction: