First Name
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Last Name
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Date of birth
*
Gender
*
Current Weight:
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Height:
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Phone
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Email
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Occupation:
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Work Schedule:
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Day Shift
Night Shift
Rotating Schedule
Work From Home
Hybrid
Has your doctor ever said that you have a heart condition AND that you should only do physical activity recommended by a doctor?
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No
Yes
Do you feel pain in your chest when you do physical activity?
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No
Yes
In the past month, have you had chest pain when you were not doing physical activity?
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No
Yes
Do you lose your balance because of dizziness or do you ever lose consciousness?
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No
Yes
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
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No
Yes
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
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No
Yes
Do you know of ANY OTHER REASON why you should not do physical activity?
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No
Yes
Current Medical Conditions. (Check all that apply)
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Obesity
Prediabetes
Type 2 Diabetes
PCOS
Hypothyroidism
Hypertension
High Cholesterol
Sleep Apnea
IBS
Anxiety
Depression
Autoimmune Condition
Are you currently taking:
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Semaglutide
Tirzepatide
Retatrutide
Sermorelin
Tesamorelin
Nad+
TRT
HRT
Other Peptides
None
How long have you been taking them?
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Current Medications:
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Current dosage:
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Have you recently increased or decreased your dosage?
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No
Yes
If yes, please explain:
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Side Effects Experienced:
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Nausea
Constipation
Diarrhea
Reflux
Fatigue
Dizziness
Appetite Suppression
Food Aversion
Muscle Loss Concerns
Hair Loss
None
What are our top three goals?
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Fat Loss
Muscle Gain
Body Recomp
Improved Energy
Better Sleep
Improved Confidence
Improved Health Markers
Blood Sugar Control
Hormone Optimization
Athletic Performance
Longevity
What would make this program a success for you in the next 90 days?
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What would make this program life-changing for you over the next 12 months?
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How many meals do you typically eat daily?
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Estimated Daily Protein Intake
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Daily Water Intake:
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How many times per week do you consume:
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Fast Food
Restaurant Meals
Alcohol
Sugary Beverages
Desserts/Sweets
Biggest Nutrition Challenges
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Emotional Eating
Portion Control
Sugar Cravings
Snacking
Dining Out
Meal Planning
Meal Prep
Low Protein Intake
Inconsistent Eating Schedule
Late-Night Eating
Boredom Eating
Mindless Eating
Food Allergies or Sensitivities:
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Dietary Preferences
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What time do you typically eat your:
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First Meal:
Last Meal:
How often do you currently track food?
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Current Activity Level
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Current Exercise Types
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Walking
Strength Training
Running
Cycling
HIIT
Yoga
Pilates
Sports
Available Equipment
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Gym Membership
Home Gym
Dumbbells
Resistance Bands
Treadmill
Bike
Rowing Machine
Exercise Frequency: (per week)
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Injuries, Limitations, or Pain:
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How many steps do you average daily?
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How confident are you in your ability to exercise consistently?
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Average Hours of Sleep Per Night:
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Rate Your Sleep Quality:
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How often do you wake feeling refreshed?
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Typical Wake Time:
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Typical Bedtime:
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Do you struggle with:
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Falling Asleep
Staying Asleep
Waking Too Early
Racing Thoughts
Restless Sleep
Night Sweats
Snoring
Sleep Apnea
Frequent Bathroom Trips
None
How often do you use screens within 60 minutes of bedtime?
*
What are your biggest sleep challenges?
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What are your biggest sleep strengths?
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Do you currently use:
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Melatonin
Magnesium
Prescription Sleep Medication
CBD
None
Current Stress Level:
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How often do you feel overwhelmed?
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When stressed, you tend to:
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Emotional Eat
Overeat
Skip Meals
Crave Sugar
Avoid Exercise
Sleep Poorly
Isolate
Scroll Social Media
Drink Alcohol
Current Stress Management Practices:
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Walking
Exercise
Prayer
Meditation
Journaling
Therapy
Coaching
Deep Breathing
Time Outdoors
None
How often do you intentionally practice self-care?
*
Do you experience:
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Brain Fog
Fatigue
Burnout
Difficulty Concentrating
Afternoon Energy Crash
Irritability
None
Rate your average energy level:
*
What drains your energy the most?
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What helps you feel most energized?
*
Biggest Sources of Stress:
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Signature
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Clear
