Supplement Optimization Activation

Integrated Wellness Supplement Optimization Activation

Tell us your goals, current products, and health context so our team can review your supplement needs. For lifestyle and symptom questions, think about the past 7 days. This form does not diagnose a deficiency or authorize a supplement plan.
Contact and Profile
Full name

First NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
Email
example@example.com
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Age
Sex at birth

Other
Height in inches
Current weight in lbs.
Goals
Primary health goals
Which ONE goal is your highest priority?
How much does this concern affect your daily life over the past 7 days?
0 = No impact; 10 = Unable to carry out usual activities.
What specific change would make the next 30 days successful?
What would you most like to improve over the next 3 months?
Current health
Overall health rating
Daily energy
Daytime fatigue frequency
Stress level

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Sleep quality
Average sleep duration
Reported symptoms

During the past 7 days, how often did each symptom occur? Leave blank if unsure.
Brain fog or difficulty concentrating
Afternoon energy crashes
Difficulty falling asleep
Waking during the night
Waking unrefreshed
Poor exercise recovery
Persistent muscle soreness
Muscle cramps
Joint stiffness or discomfort
Bloating or gas
Constipation or irregular bowel movements
Sugar or carbohydrate cravings
Reduced motivation
Feeling overwhelmed or unable to relax
Nutrition and Hydration
Daily vegetable servings
Protein intake
Daily water intake
Processed food frequency
Alcohol intake
Exercise and Activity
Exercise days per week
Primary exercise type
Average daily step count
Health and medication review
Current prescription and over-the-counter medicines
Name, dose, and frequency; include hormone and thyroid medicines. Enter None, Unsure, or Prefer to discuss if needed.
Allergies or previous reactions to medicines, foods, or supplements
Item and reaction. Enter None, Unsure, or Prefer to discuss if needed.
Health conditions, planned procedures, or clinician instructions relevant to supplement use
Include kidney or liver conditions, bleeding problems, upcoming surgery, and any instruction to avoid supplements. Enter None, Unsure, or Prefer to discuss if needed.
Are you pregnant, breastfeeding, or trying to conceive?
Recent laboratory results available for review?
You do not need a Healthie account to complete this form. Our team will provide instructions for securely sharing laboratory reports after your Healthie profile is created. Do not paste full laboratory reports or upload identifying documents here.
Current Supplements
List every supplement you currently use
One product per line: product and brand; ingredient strength and units (mg, mcg, IU); amount taken; days per week and timing; start date if known; reason for use. Include powders, gummies, herbs, pre-workout products and occasional products. Write None if you use none, or Unsure for missing details.
How consistently do you take your supplements?
Lifestyle and Preferences
Do you smoke or vape?
Preferred supplement forms
Special diet
Monthly supplement budget
Final Details
Based on your responses, would you like information about a more comprehensive Integrated Wellness Optimization Program that may include telemedicine, laboratory testing, body-composition analysis, wearable data, and clinician-guided recommendations?
A clinician or pharmacist should review medicines, supplements, allergies and relevant health conditions before you start or change a supplement. Completing this form does not approve a plan or guarantee benefit.
Is there anything else you would like our team to know?
Acknowledgment and educational use consent
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Integrated Wellness Supplement Optimization Activation

Contact and Profile

Goals

Current health

Reported symptoms

Nutrition and Hydration

Exercise and Activity

Health and medication review

Current Supplements

Lifestyle and Preferences

Final Details