Metabolic Optimization Activation

Metabolic Optimization Program Intake

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Client ID
Metabolic Goals
Primary metabolic goal
In your own words, what change do you most want to feel?
Energy & Symptom Patterns
How is your daily energy?
Do you experience energy crashes after meals?
Do you have frequent hunger or cravings, especially for carbs/sugar?
Do you get shaky, irritable, or foggy if a meal is delayed?
Eating Patterns
Describe your typical eating pattern.
Do you follow a specific diet?

Other
What time do you typically have your first meal?
What time do you typically have your last meal?
How often do you have sugary or processed foods?
How many sugary drinks or juice do you have per day?
Are you currently doing any fasting or time-restricted eating?
Metabolic Markers & History
Have you had any prior diagnoses or findings?
Is there a family history of type 2 diabetes?
Do you use a glucose monitor or CGM?
Are you currently using or considering GLP-1 (semaglutide/tirzepatide) or other weight/metabolic medication?
Activity & Engagement
Current activity level outside of exercise
Do you use a wearable or smart scale?
How many days per week can you realistically commit to this program?
Current Measurements
Date completed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current weight
Enter pounds or kilograms.
Height
Enter inches or centimeters.
Waist circumference
Enter inches or centimeters.
Most recent blood pressure, if known
Enter systolic/diastolic pressure; include mmHg if known.
Sleep, Stress & Activity
Average sleep hours per night
Enter a number of hours.
Sleep quality
Diagnosed or suspected sleep apnea
Current stress level
Average daily steps
Enter your best estimate.
Exercise days per week
Enter a whole number from 0 to 7.
Medical & Metabolic History
Which of the following apply to you?
Medications & Allergies
Current prescription medications
If none, please write none.
Current supplements
If none, please write none.
Medication allergies or significant adverse reactions
If none, please write none.
Previous metabolic or weight-loss medications
If using a GLP-1, provide the medication name, current dose, date of last dose change, and prescribing clinician
Laboratory Context
Date of most recent laboratory testing

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are current laboratory results already available in the linked medical record?
A1c
Include units if known, or write unknown.
Fasting glucose
Include units if known, or write unknown.
Fasting insulin
Include units if known, or write unknown.
Total cholesterol
Include units if known, or write unknown.
LDL-C
Include units if known, or write unknown.
HDL-C
Include units if known, or write unknown.
Triglycerides
Include units if known, or write unknown.
ALT/AST
Include units if known, or write unknown.
Creatinine/eGFR
Include units if known, or write unknown.
Medical Review
Pregnancy, trying to conceive, or breastfeeding when applicable
Recurrent low blood sugar or readings below 70 mg/dL
Severe or persistent abdominal pain
Repeated vomiting or inability to maintain hydration
Have you experienced any of the following?

Other
Any other urgent medical concern
If none, write none.
Anything else the medical team should know?
Acknowledgment
Signature
Should be Empty:

Metabolic Optimization Program Intake

Metabolic Goals

Energy & Symptom Patterns

Eating Patterns

Metabolic Markers & History

Activity & Engagement

Current Measurements

Sleep, Stress & Activity

Medical & Metabolic History

Medications & Allergies

Laboratory Context

Medical Review

Acknowledgment