What are your primary health goals?
Lose weight and optimize metabolism
Increase energy and reduce fatigue
Balance hormones and restore vitality
Improve athletic performance and recovery
Anti-aging and longevity optimization
IV therapy for immediate wellness
Aesthetic enhancement (skin, appearance)
How would you rate your current energy levels?
1 Completely exhausted, can barely function
2
3
4
5 Moderate energy, but not optimal
6
7
8
9
10 Excellent energy all day
How would you rate your sleep quality?
1 Terrible sleep, wake frequently, never rested
2
3
4
5 Decent sleep but not restorative
6
7
8
9
10 Deep, restorative sleep every night
Are you satisfied with your current weight?
Yes, I'm at my ideal weight
No, I'd like to lose 10-20 pounds
No, I'd like to lose 20-40 pounds
No, I'd like to lose 40+ pounds
I'd like to gain muscle/weight
How often do you experience brain fog or difficulty concentrating?
Never or rarely
Occasionally (1-2 times per week)
Frequently (3-5 times per week)
Daily or constantly
Do you experience cravings or difficulty controlling your appetite?
No, my appetite is well-controlled
Occasional cravings, manageable
Frequent cravings that interfere with my goals
Constant hunger or out-of-control cravings
How often do you feel stressed or overwhelmed?
Rarely or never
Occasionally
Frequently (most days)
Constantly or daily
Have you been diagnosed with any of the following? (Select all that apply)
Prediabetes or Type 2 Diabetes
High blood pressure
High cholesterol
Thyroid disorder
Insulin resistance or PCOS
Metabolic syndrome
None of the above
[Gender-Specific — Male Version] Are you experiencing any of the following?
Low libido or sexual dysfunction
Difficulty building or maintaining muscle
Increased body fat (especially abdominal)
Mood changes or irritability
Reduced motivation or drive
None of the above
[Gender-Specific — Female Version] Are you experiencing any of the following?
Hot flashes or night sweats
Irregular periods or menopause symptoms
Low libido
Mood swings or anxiety
Weight gain (especially around midsection)
None of the above
How quickly do you recover from exercise or physical activity?
I recover quickly (within 24 hours)
Moderate recovery (1-2 days)
Slow recovery (3+ days)
I avoid exercise due to fatigue or pain
Have you tried other weight loss or health optimization programs before?
No, this is my first time seeking help
Yes, but they didn't work long-term
Yes, and I saw some results but plateaued
I've tried many programs with little success
How soon are you looking to start a health optimization program?
Immediately (this week)
Within the next 2-4 weeks
Within the next 1-2 months
Just exploring options for now
What is your monthly budget for health optimization?
Less than $200/month
$200-$400/month
$400-$600/month
$600-$1,000/month
$1,000+/month
I'm not sure yet
How many times per month do you plan to visit the clinic?
Once per month
2-3 times per month
Weekly or more
Telehealth only (no in-person visits)
Not sure yet
Are you currently taking any medications or supplements?
Yes
No
Do you have any major medical conditions we should know about?
Yes
No
What is your gender?
Male
Female
Prefer not to say
What is your age range?
18-29
30-39
40-49
50-59
What is your preferred language?
English
Español
Both (bilingual)