Integrated Wellness Optimization Activation

Integrated Wellness Optimization Activation
Client Information
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex assigned at birth
Height (inches)
Current weight (lbs.)
Goal weight (lbs.)
Waist circumference (inches)
Body fat percentage (approximate)
Optimization Focus
Which program fits best?
Primary goal
Secondary goals
What would success look like in 90 days?
Why optimize now?
What have you already tried, and what helped or did not help?
Body Composition & Metabolic Signals
Recent DEXA, InBody, or body composition data available?
Recent weight change
How easy is it to lose body fat right now?
Which metabolic signals stand out most?

Other
Which nutrition patterns apply right now?

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?
How is recovery after training?
How sore do you usually feel after training?
Top 3 current symptoms or performance limitations
What tends to make your symptoms or performance worse?
Sleep & Circadian
Average sleep hours per night
How would you rate your sleep quality?
How consistent is your bedtime?
How consistent is your wake time?
Which sleep issues apply?

Other
Do you use wearable sleep data?
If yes, which wearable or data source?
Energy & Recovery
Overall daily energy
Morning energy
Afternoon energy
How often do you feel fatigued?
Recovery quality
Resilience after hard training or stressful days
Hormonal Optimization Signals
Which hormonal signals apply?

Other
Current hormone or thyroid optimization therapy?
If yes, what therapy and current use?
Gut & Microbiome
Which gut signals apply?

Other
Is microbiome testing available?
Stress & Resilience
How stressed do you feel day to day?
How well do you recover from stress?
How does stress usually affect you?

Other
Cognitive Optimization
Which cognitive signals apply?

Other
Inflammation & Recovery Signals
Which inflammation or recovery signals apply?

Other
Current Optimization Tools
Current supplements or therapies
Available Data
What data is available for review?

Other
If your recent labs or documents include identifying information, please upload them through your secure Healthie account instead of this form.
Cardiovascular Fitness
Resting heart rate (if known)
Blood pressure (if known)
Perceived aerobic fitness
Exercise breathlessness
Endurance
Wearable VO2 max or cardio fitness available?
Nutrient & Methylation
Known nutrient concerns

Other
Alcohol intake pattern
Current nutrient supplements
Is DNA or genomic data available?
Overall 0-10 impact
What tends to make your symptoms or performance better?
Current optimization therapies
Objective labs from the last 12 months available?
Most important outcome to track
What would make this program feel successful at 30 days, 90 days, and 6 months?
Readiness & Support
How ready are you to make changes now?
How confident are you in following a plan?
What support would help most?
What changed around the time these issues began?
Minimal Health Routing
Is there an active health issue, concerning symptom, or physician-managed condition that could affect participation?
If yes, briefly explain
Should be Empty:

Integrated Wellness Optimization Activation

Client Information

Optimization Focus

Body Composition & Metabolic Signals

Training & Performance

Sleep & Circadian

Energy & Recovery

Hormonal Optimization Signals

Gut & Microbiome

Stress & Resilience

Cognitive Optimization

Inflammation & Recovery Signals

Current Optimization Tools

Available Data

Cardiovascular Fitness

Nutrient & Methylation

Readiness & Support

Minimal Health Routing