Book Your Wellness Assessment

Contact Information

First name Last name Email Phone Country State / Province

Date of birth

Body Measurements

Enter what you know now — approximate is fine.

Height (ft / in)

Weight ()

Waist ()

Hip ()

Chest ()

Lifestyle

Smoke

Yes No

Vape

Yes No

Cannabis

Yes No

Recreational drugs

Yes No

Insomnia

Yes No

Work / Daily Activity

How would you describe your usual workday activity?

Work Schedule

Part-time Full-time Not currently working

Daily Activity

Sitting most of the day Mostly standing Frequent walking

Physical Work

Physical work / constant movement Heavy physical work

Exercise / Additional Weekly Activity

Do you exercise or participate in physical activities outside of work?

Examples: gym, weight training, Zumba, dance, yoga, Pilates, running, cycling, sports, or other physical activities.

None 1–2 times per week 3–4 times per week 5+ times per week

Activity or activities you perform:

Current Supplements

Do you currently take or use any supplements?

Yes No

What form? (Select all that apply)

Capsules / tablets Powder Injection Vitamin IV Other

Which ones?

Current Prescription Products

Do you currently take prescription products for any of the following?

Diabetes

Yes No

High blood pressure

Yes No

High cholesterol

Yes No

Depression / Anxiety

Yes No

Insomnia

Yes No

Allergies

Yes No

Please list the prescription products you currently use. Write "None" if this does not apply.

Previous surgeries?

Yes No

Other health condition

Your Goals

What are the two things you'd most like to achieve?

Main goal #1 Main goal #2

Anything Else?

Comments (optional) — anything else you'd like us to know

Documents

Upload your recent laboratory results and receive an $80 Wellness Credit toward products during your Initial Wellness Assessment. Laboratory reports are completely optional.

Laboratory reports (PDF or image, optional)

Body photos (optional — can be added after your consultation)

Privacy and Data Protection

The information you provide will be treated as private and used only to evaluate your wellness and nutrition needs. Access is restricted to authorized staff. Please do not submit emergency medical information through this form.

Registration completed successfully.

Contact Information

Body Measurements

Lifestyle

Work / Daily Activity

Work Schedule

Daily Activity

Physical Work

Exercise / Additional Weekly Activity

Current Supplements

Current Prescription Products

Your Goals

Anything Else?

Documents

Privacy and Data Protection