Mindset, Muscle & Nutrition Please fill out the questionnaire below so we can learn about you, your experiences with GLP1 medications, and your Health and Fitness goals. Step 1 of 5 20% About YouYour Name(Required) First Last Age(Required)Please enter a number from 18 to 99.Weight(Required)This is needed for calculating macros.HeightYour Address Street Address Address Line 2 City ZIP Code How Can We Reach You?We would love to chat with you. How can we get in touch?Your Email Address(Required) Email Address Confirm Email Address Your Phone(Required) GLP1 MedicationDisclaimer Your health and safety are important to us. Our services are limited to providing general fitness, nutrition, and lifestyle guidance; we are not licensed medical professionals. We do not provide medical diagnosis, treatment, or advice regarding medications or health conditions. If you are currently using medications such as GLP-1 drugs or have any health concerns, please consult with your healthcare provider before beginning any new exercise or nutrition program. By participating in our program, you acknowledge that you have been advised to seek medical clearance if necessary, and you agree to do so. We are committed to supporting your health and wellness journey safely. However, we are not responsible for any medical issues or adverse effects that may arise from following our guidance. Always follow the advice of your healthcare provider.Option to Share Medication InformationWould you like to voluntarily share information about your use of GLP-1 medication to help us better tailor your program? Your participation is optional. If you choose to share this information, it will be used solely to enhance your personalized support and will be kept confidential. Yes, I choose to share this information. No, I prefer not to share this information. You have opted out of sharing GLP1 medication data. Please continue to the next page.GLP1 Medication DetailsAre you currently taking GLP1 medications? Yes No GLP1 Start DatePlease indicate roughly when you begin taking GLP1 medication. MM slash DD slash YYYY Have you taken GLP1 medications in the past? Yes No GLP1 End DatePlease Indicate Roughly When you stopped taking GLP1 Medications MM slash DD slash YYYY GLP1 GoalsGLP1 Medication GoalsWhat are your main goals for using GLP1 medication? Weight Loss Appetite Control Blood Sugar Regulation GLP1 Future PlansWe will work with you no matter your future plans and goals for GLP1 medication. We'd like to know what your plans are so we can tailor our program to support your goals. Select...Decrease UsageStop UsageContinue As IsSide EffectsPossible Side EffectsHave you experienced any side effects since starting GLP1 medication? Muscle Loss Weakness Nausea Fatigue Vomiting Diarrhea Constipation Abdominal pain or discomfort Loss of appetite Dizziness Headaches Indigestion or acid reflux Changes in taste Pancreatitis symptoms (severe abdominal pain, nausea, vomiting) Injection site reactions (redness, swelling) Additional Comments Physical HealthPhysical ActivityAre you currently Physically Active? Yes No Sometimes Physical ActivityDescribe your physical activities and frequency.LimitationsPhysical LimitationsDo you have any physical Limitations or Injuries? Yes No Sometimes Physical LimitationsDescribe any physical imitations or injuries we'll need to work around. NutritionCurrent nutritionWhat is your current nutrition like? Help Me Meh Good-ish Diet Is Locked In Other Nutrition DetailsDo you follow any specific diet? Any food allergies? If so, tell me more.Nutrition GoalsWhat is your goal for the next 3 months? Anything Else On Your Mind?Your Comments/Questions(Required) Δ
