BluefitMD Wellness Blueprint

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

Full Name *

Email

Age *

Sex *

Select

Height *

Current Weight *

Goal Weight *

Desired Timeline To Reach Your Goal *

B. Medical & Medication

Do you have any medical conditions? *

Are you currently taking any medications? (please list including dosage and purpose) *

Which GLP-1 medication are you on? *

Select...

Current Dose (Which MG?) *

Start Date / How Long on Medication *

Frequency *

How often do you take it?

Administration Method *

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Side Effects *

C. Nutrition & Medication

Current Eating Habits *

Daily Protein Intake *

How much protein do you estimate you consume daily?

Food Tracking *

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If yes, how do you track your food?

Allergies or Intolerances *

Daily Water Intake *

D. Exercise & Activity

Current Exercise Routine *

Do you exercise?

How often do you exercise (per week)?

What type of exercise do you do?

How intense are your workouts?

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Do you have access to a gym or home exercise equipment? *

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How active is your daily life outside of workouts? *

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E. Supplementation

Current Supplements *

Would you be open to adding supplements to support (select all that apply): *

Fat Loss

Muscle Retention

Energy

Gut Health

Appetite Control

Sleep

F. Lifestyle & Habits

How would you rate your sleep quality? *

Select...

Sleep Duration *

Stress Level *

Occupation *

Support System *

Do you have a strong support system?

Past Weight Loss Attempts *

Primary Motivation *

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