Your Wellness Blueprint: Perfectly Fit To You
Please fill out the form below so our medical team can review your information. Once completed, a licensed physician will assess your responses and create a personalized wellness blueprint tailored specifically to your goals, lifestyle, and health needs. Within 24 hours, your custom wellness plan will be delivered straight to your email.
A. Basic Information
Select
- Male
- Female
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B. Medical & Medication
Select...
- Semaglutide
- Tirzepatide
- Other
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- List is empty.
How often do you take it?
- Once per week
- Once every 10 days
- Once every 2 weeks
- Once every 3 weeks
- Once per month
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- List is empty.
Select...
- Self-adminster at home
- Clinic visit
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- List is empty.
C. Nutrition & Medication
How much protein do you estimate you consume daily?
- Low (< 75g/day)
- Medium (75–130g/day)
- High (130–220g+/day)
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- List is empty.
Select...
- Yes
- No
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- List is empty.
D. Exercise & Activity
Do you exercise?
- Yes
- No
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- List is empty.
Select...
- Light
- Moderate
- Intense
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- List is empty.
Select...
- Gym access
- Home equipment
- Neither
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- List is empty.
Select...
- Sedentary
- Lightly Active
- Active
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E. Supplementation
F. Lifestyle & Habits
Select...
- Poor
- Fair
- Good
- Excellent
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- List is empty.
Do you have a strong support system?
- Yes
- No
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- List is empty.
