Full Name:*

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E-mail

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Cell Number:*

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Full Address including zip code:

Age & Birthday:*

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Occupation:*

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Current Weight:*

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Goal Weight: *

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Current activity level is low

Current activity level is moderate

Current activity level is high

In the next 6-12 months, what are your top 3 outcomes? (check up to 3)

Lose 20+ pounds

Lose 10-20 pounds

Stop "weight creep" / keep weight off

Reduce cravings / emotional / late-night eating

Have more daily energy and focus

Recover faster from workouts or injuries

Sleep deeper / wake more refreshed

Strengthen my immune system / detox support

Look better (skin, hair, overall appearance)

Age well / feel younger longer

Other:

Explain other:

How important is it for you to improve your health and energy right now>

Not at all

Slightly

Neutral

Important

Very important

How much of a challenge is excess weight or body fat for you right now?

Not at all

Slightly

Moderately

Significantly

Severely

How often do you feel like your weight or midsection is slowly creeping up, even when you're trying?

Never

Rarely

Sometimes

Often

Always

Check all that applies:

I have constant thoughts about food / "food noise".

I'm guilty of nighttime snacking.

I'm guilty of overeating on the weekends or at social events.

Have you ever lost weight and then regained it within the last 2-3 years?

Yes. 5-10 lbs

Yes. 10-25 lbs

Yes. 25 + lbs

Have you used GLP-1 medications (like Semaglutide or Tirzepatide) before?

Yes - and I did well.

Yes, but I had side effects

Yes - lost weight but gained most of it back.

Do you experience chronic fatigue, low stamina, or frequent "energy crashes"?

Never

Rarely

Sometimes

Often

Always

How often do you struggle with brain fog, poor focus, or forgetfulness?

Never

Rarely

Sometimes

Often

Always

How often do you feel stressed, overwhelmed, or mentally burned out?

Never

Rarely

Sometimes

Often

Always

"I recover slower than I should from workouts, soreness, or injuries."

Never

Rarely

Sometimes

Often

Always

Do you deal with chronic joint or tendon pain that limits your training or daily activity?

Never

Rarely

Sometimes

Often

Always

Have you had lingering discomfort from an old injury or surgery?

Yes - mild

Yes - moderate

Yes - significant

How often do you struggle with poor sleep, frequent waking, or unrefreshing sleep?

Never

Rarely

Sometimes

Often

Always

Do you feel like you get sick easily or take a long time to bounce back from illness?

Never

Rarely

Sometimes

Often

Always

Are you regularly exposed to alcohol, smoking, travel, or environmental toxins (chemicals, pollution, etc.)?

Never

Rarely

Sometimes

Often

Always

How concerned are you about aging-related changes (strength, stamina, body composition)?

Not concerned

Slightly

Neutral

Concerned

Very concerned

How much do you notice things like dull skin, fine lines, thinning hair, or slower healing?

Not at all

Slightly

Moderately

Significantly

Severely

How interested are you in programs focused on longevity and aging well (not just quick fixes)?

Not interested

Somewhat interested

Very interested

Extremely interested

Which best describes your current weight situation?

I want to lose 20 + lbs.

I want to lose 10 - 20 lbs.

I am close to my goal weight, but fighting slow weight gain or "menopause belly".

My main goal is not big weight loss. I care more about control, consistency, and how I feel.

How often do you feel like your habits are mostly good, but hormones, stress, or age are still pushing your weight, cravings, or blood sugar in the wrong direction?

Never

Rarely

Sometimes

Often

Always

Which of these sound like you? (check all that apply)

I want gentle appetite and craving control without a high dose protocol.

I'm worried about nausea or side effects from full-dose GLP-1 medications.

I've done a GLP-1 program and want to maintain results on a lighter plan.

I have blood sugar / insulin resistance concerns and want extra support staying stable.

I'm dealing with inflammation, aches, or "puffy" weight tied to sess or hormones

I'm in perimenopause or menopause and notice stubborn midsection gain and cravings

I'm in a high-stress, travel, or event-heavy season and need help staying consistent.

Have you ever been told by a doctor that you should not take GLP-1 medications (Ozempic, Wegovy, Mounjaro, Zepbound, etc.)?

Yes

If yes, why?

Have you ever been diagnosed with any of the following? (check all that apply)

Type 1 diabetes

Uncontrolled Type 2 diabetes

History of pancreatitis

History of medullary thyroid cancer or MEN2

Severe GI disease (gastroparesis, severe Crohn's, etc.)

Active cancer treatment

None of the above / not sure

Are you currently?

Pregnant

Breastfeeding

Planning pregnancy in the next 6 months

None of the above

Major current health conditions or concerns you think the medical provider should know about:

Current prescription medication or major supplements:

By submitting this form, I consent to KP and its affiliated healthcare providers collecting, storing, and processing the personal and health information I provide for the purposes of evaluating my eligibility for services, coordinating care, communicating with me regarding my treatment options, and maintaining required medical records. I understand that my information will be handled in accordance with applicable privacy laws and security standards. I may request access to, correction of, or deletion of my personal information where permitted by law. I understand that submitting this form does not guarantee approval for any treatment or service and does not establish a provider-patient relationship until formally accepted by a licensed healthcare provider. I have read and agree to the Privacy & Data Processing Consent.*

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Client Health & Goal Assessment