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Comprehensive Wellness Therapy Survey Form

This form helps our medical team determine your eligibility and readiness for therapies including GLP-1s, NAD+, Glutathione, and Sermorelin. Your responses allow us to tailor care to your goals and health history.

⚠️ Please note: Your appointment will be cancelled if this survey questionnaire is not submitted before your scheduled time.

Personal Information

Full Name *

Email *

Date of Birth *

Gender *

Male

Female

Non-Binary

Prefer not to say

Awareness & Education

Did you know...

● NAD+ declines up to 50% between ages 40–60?

● Glutathione levels drop with age, toxins, stress, and medications?

● HGH declines ~14% per decade after age 30?

Awareness & Education *

Yes — and I’ve felt the difference

I’ve heard of this but didn’t realize the effects

No — this is new to me

Motivation & Lifestyle Impact

How have these symptoms affected your life, relationships, or self-image? (Example: I’m tired all the time. I can’t enjoy family time or perform well at work.) *

If your energy, body, or focus improved, what would that unlock for you? (Example: I’d feel confident again. I’d lead better. I’d get back to hobbies or the gym.) *

Additional Notes

Is there anything else you'd like our medical team to know about your health or goals? *

Partner performs non-clinical services and does not practice medicine or pharmacy. Licensed providers independently determine clinical eligibility and prescribing.

No Professional Services: obligations are non-clinical; parties do not practice medicine, nursing, or pharmacy.

Disclaimer: No Medical Advice

The information provided herein is for informational and educational purposes only and is not intended as, nor should it be construed as, medical advice, diagnosis, or treatment. Nothing contained in this content, platform, communication, or related materials should be considered a substitute for professional medical advice, diagnosis, or treatment from a licensed healthcare provider. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment. Never disregard professional medical advice or delay in seeking it because of something you have read, heard, or accessed through this platform. Reliance on any information provided is solely at your own risk.

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