Integrated Wellness Optimization Activation
Client Information
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex assigned at birth
*
Female
Male
Intersex
Prefer not to say
Height (in.)
Enter your height in inches.
Current weight (lb)
Goal weight (lb)
Waist circumference (in.)
Body fat percentage (%, approximate)
Optimization Focus
Which optimization program fits best?
Body Composition
Metabolic
Hormonal
Performance
Longevity
Microbiome
Cognitive
Life Optimization
Not Sure
Primary goal
Secondary goals
Body composition
Energy
Sleep
Strength
Endurance
Hormonal balance
Digestion
Focus
Stress resilience
Longevity
What would success look like in 90 days?
Why now?
What have you tried, and what helped or didn’t help?
Body Composition & Metabolic Signals
Recent weight change
Gained
Lost
No major change
Not sure
How easy is it to lose body fat right now?
Very easy
Somewhat easy
About average
Somewhat hard
Very hard
Which metabolic signals stand out most?
Strong appetite
Frequent cravings
Afternoon energy crashes
Blood-sugar concerns
Low appetite
Emotional eating
None of these
Other
Which nutrition patterns apply right now?
Eat 2 meals/day
Eat 3 meals/day
Eat 4+ meals/day
Structured meal timing
Higher-protein focus
Calorie tracking
Macro tracking
Low-carb approach
Mediterranean-style
Plant-based
Intermittent fasting
Other
Any food intolerances or major restrictions?
Training & Performance
Exercise days per week
Strength training days per week
Cardio days per week
Daily activity or walking
How would you rate your current fitness level?
Very low
Low
Moderate
Good
Very good
How is recovery after training?
Excellent
Good
Okay
Poor
Very poor
How sore do you usually feel after training?
Not sore
Mildly sore
Moderately sore
Very sore
Top 3 current symptoms or performance limitations
What tends to make your symptoms or performance worse?
Time of day
Poor sleep
Stress
Training
Travel
Diet
Alcohol
Workload
Injury
Illness
Medication or therapy change
No clear pattern
Sleep & Circadian
Average sleep hours per night
How would you rate your sleep quality?
Very poor
Poor
Fair
Good
Very good
How consistent is your bedtime?
Very consistent
Somewhat consistent
Inconsistent
Very inconsistent
How consistent is your wake time?
Very consistent
Somewhat consistent
Inconsistent
Very inconsistent
Which sleep issues apply?
Trouble falling asleep
Wake during the night
Do not wake refreshed
Daytime sleepiness
Other
Energy & Recovery
Overall daily energy
Very low
Low
Moderate
Good
Very good
Morning energy
Very low
Low
Moderate
Good
Very good
Afternoon energy
Very low
Low
Moderate
Good
Very good
How often do you feel fatigued?
Rarely
Sometimes
Often
Almost always
Recovery quality
Very poor
Poor
Fair
Good
Very good
Hormonal Optimization Signals
Which hormonal signals apply?
Libido changes
Sexual function changes
Menstrual cycle changes
Perimenopause symptoms
Menopause symptoms
Temperature intolerance
Hair changes
Skin changes
Other
Are you currently on hormone or thyroid optimization therapy? If yes, what therapy and current use? Include dosages and frequency.
Gut & Microbiome
Which gut signals apply?
Bloating
Gas
Reflux
Constipation
Diarrhea
Food reactions
Irregular bowel regularity
Digestive discomfort
Other
Stress & Resilience
How stressed do you feel day to day?
Very low
Low
Moderate
High
Very high
How well do you recover from stress?
Very well
Well
Okay
Poorly
Very poorly
How does stress usually affect you?
Sleep
Eating
Training
Mood
Motivation
None of these
Other
Cognitive Optimization
Which cognitive signals apply?
Focus issues
Memory issues
Brain fog
Mental stamina issues
Motivation issues
Productivity issues
Lower perceived cognitive performance
Other
Inflammation & Recovery Signals
Which inflammation or recovery signals apply?
Joint discomfort
Muscle soreness
Slow recovery
Swelling or puffiness
General aches
Limits training or daily function
Other
Cardiovascular Fitness
Resting heart rate (bpm, if known)
Blood pressure (mmHg) (If known)
Perceived aerobic fitness
Very low
Low
Moderate
Good
Very good
Endurance
Very low
Low
Moderate
Good
Very good
Supplements and Medications
Are you taking supplements? If so, please include which ones, dosages, and frequency.
Known nutrient concerns
Vitamin D
B12/folate
Iron/ferritin
Homocysteine
None known
Are you taking any medications? If so, please include which ones, dosages, and frequency.
Readiness & Support
How ready are you to make changes now?
Not ready
Slightly ready
Moderately ready
Very ready
How confident are you in following a plan?
Not confident
Somewhat confident
Confident
Very confident
What support would help most?
Nutrition
Training
Accountability
Sleep
Stress
Gut
Cognitive
Hormonal
Metabolic
Body composition
Longevity
Data review
Health Routing
Is there an active health issue, concerning symptom, or physician-managed condition that could affect participation? If yes, briefly explain
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