First Name
Last Name
Email
*
What were your original health goals when you joined our program:
General Wellness Checkup
Improve energy, mood and mental acuity
Achieve fitness / weight gain or weight loss goals
Prevent or correct chronic illness
Enhance sexual health
Balance hormone health
Learn more about longevity and regenerative options
Discuss the latest biohacking methods
Other
Where have you noticed the most improvement since you started with AMI?
In what ways have you improved in that area?
What was your most recent blood pressure reading?
What was your most recent heart rate?
What is your current weight?
If you were grading yourself A through F how would you grade yourself in these areas in the last few months? (Standard academic grading scale; A+ being the best, F being failing)
Sleep
A
B
C
D
F
Nutrition
A
B
C
D
F
Exercise
A
B
C
D
F
Energy
A
B
C
D
F
Libido
A
B
C
D
F
Following Your Treatment Plan
A
B
C
D
F
Stress Management
A
B
C
D
F
Do you feel like you have a clear understanding of your treatment plan? Y or N
Do you feel like you have a clear understanding of your treatment plan? Y or N
Yes
No
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Is there anything that has been holding you back from excelling in the above fields?
Since you have begun treatment with EHP have any new goals come up for you? Please list below:
What has been the most outstanding part of your experience with EHP so far?
In what ways could we serve you better?
What other services would you be interested in learning more about?
What other services would you be interested in learning more about?
Hormone Replacement Therapy
NAD+ Therapy
Peptide Therapy
Sexual Health
Stem Cell Exosome Therapy
Weight Loss Therapy
Galleri Multi-Cancer Early Detection
Genova Stool Testing
Hair Analysis Intolerance & Sensitivity
NAD+ Intercellular
Salivary Cortisol
TruAge Epigenetic
Wise Diagnostic Blood & Stool
Parasite Testing
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Is there anything else you would like to share before your follow up Consultation with our team?