What is your primary wellness goal right now?

Boost energy and mental clarity

Lose weight and control appetite

Improve sleep quality and reduce stress

Heal from injury, pain or inflammation

Support longevity and anti-aging

Optimize hormones and sexual wellness

How would you describe your energy levels during the day?

Constantly tired or sluggish

Low in the morning, better later

Pretty consistent

Wired but tired

How do you currently sleep?

Trouble falling asleep

Wake up frequently

Feel unrefreshed in the morning

I sleep fine

What is your biggest challenge with your weight?

I gain weight easily, especially in the abdomen

I can't lose weight despite diet/exercise

I emotionally overeat or snack late

I'm doing well but want more body composition support

Do you experience any of the following? (Check all that apply)

Brain fog

Poor focus or memory

Mood swings

Anxiety or overwhelm

Have you recently dealt with injury, surgery, or chronic inflammation?

Yes - muscle, joint or ligament related

Yes - gut or systemic inflammation

No, but I train intensely and want recovery

What best describes your current skin, hair or aging concern?

Loss of skin elasticity/wrinkles

Hair thinning or shedding

Want to prevent aging before it starts

None of these

Do you struggle with libido or sexual wellness?

Yes, low libido or arousal

Vaginal dryness or poor sensitivity

I'd like to enhance intimacy

No concerns

What is your approach to aging?

I want to live longer and feel younger

I'm interested in regenerative and anti-aging treatments

I just want to feel better now

Do you have known gut issues or food sensitivities?

Yes - bloating, reflux, GI distress

History of mold exposure or autoimmunity

I take daily probiotics and try to support my gut

Do you prefer oral, injectable or nasal treatments?

Oral only

Comfortable with injectables

Nasal or topical preferred

Would you like our Medical team to create a full functional wellness treatment plan for you?

Yes! Aesthetics consult

Yes! I'd like to have my labs ordered for you to put into your diagnostics software to analyze root causes

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