• Integrated Wellness Supplement Optimization Intake

    Complete this intake with your health, nutrition, activity, goals, and supplement details so we can review your needs.

  • Contact and Profile

  • Format: (000) 000-0000.
  • Sex at birth*

  • Goals

  • Primary health goals*

  • Current health

  • Overall health rating
  • Daily energy
  • Daytime fatigue frequency
  • Sleep quality
  • Average sleep duration

  • Reported symptoms

    How often have you experienced the following recently?
  • 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

  • Current Supplements

  • How consistently do you take your supplements?

  • Lifestyle and Preferences

  • Do you smoke or vape?
  • Preferred supplement forms
  • 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?*
  • Should be Empty: