Male Body Transformation Medical Intake Form
Answer a few targeted questions so the care team can personalize your 12-week recomposition plan and route any safety-related items for provider review.
Client ID
*
Goals & Care Plan Intent
Primary Care Goal
*
Fat loss
Lean muscle gain
Body recomposition
Strength improvement
Higher energy
Metabolic health
Hormone-related symptom support
GLP-1 support
Long-term lifestyle optimization
Other
Secondary Care Goals
Fat loss
Lean muscle gain
Body recomposition
Strength improvement
Higher energy
Metabolic health
Hormone-related symptom support
GLP-1 support
Long-term lifestyle optimization
Other
What would success look like over the next 12 weeks?
Readiness / Urgency
*
Just exploring
1
2
3
4
Ready to start now
5
1 is Just exploring, 5 is Ready to start now
Current Body Composition
Height (inches)
Weight (lbs)
Waist (inches)
Estimated Body Fat Percentage (%)
Training & Movement
How many days per week do you currently train?
0
1-2
3-4
5-6
7+
What types of training do you currently do?
Strength training
Cardio
Sports
Classes
Mobility/Flexibility
Walking
Other
How would you describe your overall weekly activity level?
Mostly sedentary
Lightly active
Moderately active
Very active
Extremely active
Average daily steps, if known
Any movement limitations or concerns
Please describe any injuries, pain, or exercise restrictions that affect training
What kind of training plan can you realistically follow right now?
Nutrition & Eating Habits
Typical meal pattern
5+ meals per day
4 meals per day
3 meals per day
2 meals per day
1 meal per day
Grazing/snacking throughout the day
Irregular
How consistent is your protein intake?
Very inconsistent
1
2
3
4
Very consistent
5
1 is Very inconsistent, 5 is Very consistent
Which eating schedule best describes you?
Regular meal times
Intermittent fasting
Late-night eating
Frequent skipped meals
Shift-work schedule
Other
Daily hydration habit
Under 1 liter
1–2 liters
2–3 liters
3+ liters
Varies a lot
Not sure
Alcohol intake
None
Rarely
1–2 days per week
3+ days per week
Varies
Prefer not to say
Common nutrition barriers
Sleep, Stress & Recovery
Average sleep duration per night (hours)
Sleep quality
Very poor
1
2
3
4
Excellent
5
1 is Very poor, 5 is Excellent
Current stress level
Very low
1
2
3
4
Very high
5
1 is Very low, 5 is Very high
Which recovery habits do you regularly use?
Stretching
Mobility work
Foam rolling
Massage
Breathwork
Meditation
Sauna
Cold exposure
Active recovery walks
Other
What are your most common recovery barriers?
Late bedtime
Inconsistent sleep schedule
Frequent waking
Waking unrefreshed
Work stress
Family stress
Physical soreness
Low energy
Poor nutrition timing
Screen time before bed
Other
How consistent is your bedtime?
Very consistent
Somewhat consistent
Inconsistent
Very inconsistent
Metabolic & Appetite Signals
Appetite Changes Experienced
Reduced appetite
Increased appetite
Fluctuating appetite
No notable change
Cravings Experienced
Sugary foods
Salty snacks
Late-night snacking
Frequent hunger
Unusual cravings
Describe Your Main Cravings or Appetite Changes
When Do Cravings or Energy Crashes Usually Happen?
Morning
Midday
Afternoon
Evening
Late night
After workouts
Around stress
Meal Pattern Signals
Skip breakfast
Skip lunch
Skip dinner
Long gaps between meals
Irregular meal timing
Binge after skipping meals
Emotional Eating or Stress-Related Eating Signals
Eat more when stressed
Eat more when bored
Eat more when anxious
Eat less when stressed
No clear pattern
Medications or Therapies Affecting Appetite or Metabolism
Hormone & Performance Signals
Low energy or fatigue in the past 30 days
Never
Occasionally
Often
Nearly every day
Reduced drive or motivation
Never
Occasionally
Often
Nearly every day
Changes in libido or sexual interest
No change
Mild decrease
Moderate decrease
Marked decrease
Prefer not to say
Performance changes noticed
Lower strength
Reduced endurance
Slower recovery
More soreness than usual
Decreased training tolerance
Other
If you selected other symptoms, please briefly describe them
Do you have a history of eating disorders or disordered eating that should be reviewed before starting?
*
No
Yes
Not sure
Testosterone-related concerns or symptoms to review by a provider
Prostate concerns or other male health symptoms for provider review
Medical History & Safety Screening
Has a clinician ever told you that you have a heart or circulation condition that should be reviewed before starting a new training program?
No
Yes
Not sure
Which of the following medication or allergy review items apply right now?
Current medications
Supplements
Medication side effects
Allergy concerns
GLP-1 medication
Metabolic medication
Other provider-directed treatment
None of these
Other
Have you had concerns with high or low blood pressure?
No
Yes
Not sure
Have you been told you have diabetes, prediabetes, or blood sugar concerns?
No
Yes
Not sure
Have you been told you may have sleep apnea or another sleep-related breathing issue?
No
Yes
Not sure
Have you had any prostate-related concerns that should be reviewed before making training or nutrition changes?
No
Yes
Not sure
Which of the following apply right now?
Current medications
Supplements
Hormone-related treatment
GLP-1 medication
Other provider-directed treatment
None of these
List any current medications, supplements, or provider-directed treatments
Describe any current or recent injury, pain, surgery recovery, or movement limitation
Have you experienced chest discomfort, dizziness, unusual shortness of breath, fainting, or other concerning symptoms during exercise?
No
Yes
Not sure
Is there any other reason your exercise or nutrition changes should be reviewed by a provider before you start?
Progress Tracking & Data Uploads
Which progress metrics are you willing to track consistently?
Body weight
Progress photos
Waist measurement
Workout logs
Nutrition tracking
Daily steps
Wearable data
Upload screenshots or exports of wearable or tracking data
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Medical acknowledgment
*
Additional notes about your tracking setup or preferred check-in details
Motivation & Support
Motivation level for this program
Low
1
2
3
4
High
5
1 is Low, 5 is High
Anticipated barriers to adherence
Work schedule
Travel
Family responsibilities
Low energy
Stress
Cravings
Limited equipment
Injury or discomfort
Other
Preferred accountability or support style
Regular check-ins
Text reminders
Weekly progress review
More direct coaching
Minimal check-ins
Partnered accountability
Anything else the Integrated Wellness team should know to support your success
Final Confirmation
Client signature
*
Date confirmed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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