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SECTION 1 – General Information

Your answers help us understand where you are today so we can guide you toward feeling, performing, and living at your best.

First Name*

Last Name*

E-mail Address*

Phone Number*

Street Address

Birth Date*

Current Weight

Goal Weight

Current Activity Level

LowModerate

High

How did you hear of us or who referred you to KMM?

SECTION 2 – Your Top Priorities, Weight, Cravings & Metabolism

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

Lose 20+ poundsLose 10–20 pounds

Stop “weight creep” / keep weight offReduce cravings / emotional / late-night eating

Have more daily energy and focusRecover faster from workouts or injuries

Sleep deeper / wake more refreshedStrengthen my immune system / detox support

Look better (skin, hair, overall appearance)Age well / feel younger longer

Other

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

Not at allSlightly

ModeratelySignificantly

Severely

How much do you struggle with (overall): - Constant thoughts about food / “food noise” - Nighttime snacking - Overeating on weekends or social events

Not at allSlightly

ModeratelySignificantly

Severely

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

NoYes, 5–10 lbs

Yes, 10–25 lbsYes, 25+ lbs

Have you used GLP-1 medications (like semaglutide or tirzepatide) before?

NoYes – and I did well

Yes – but I had side effectsYes – lost weight but gained most of it back

SECTION 3 – Energy, Focus & Mood

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

NeverRarely

SometimesOften

Always

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

NeverRarely

SometimesOften

Always

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

NeverRarely

SometimesOften

Always

SECTION 4 – Recovery, Pain & Inflammation

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

Not at allSlightly

ModeratelySignificantly

Severely

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

NeverRarely

SometimesOften

Always

SECTION 5 – Sleep, Immune & Detox

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

NeverRarely

SometimesOften

Always

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

NeverRarely

SometimesOften

Always

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

NeverRarely

SometimesOften

Always

SECTION 6 – Healthy Aging, Appearance & Longevity

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

Not at allSlightly

ModeratelySignificantly

Severely

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

Not InterestedSomewhat Interested

Very InterestedExtremely Interested

SECTION 7 – Microdosing Fit Check

Which best describes your current weight situation?

I want to lose 20+ lbsI 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?

NeverRarely

SometimesOften

Always

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

I want gentle appetite and craving control without a high-dose protocolI’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 planI 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 hormonesI’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

SECTION 8 – Medical History & Current Health

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

NoYes → Why?

Why?

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

Type 1 diabetesUncontrolled Type 2 diabetes

History of pancreatitisHistory 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:

PregnantBreastfeeding

Planning pregnancy in the next 6 monthsNone of the above

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

Current prescription medications or major supplements:

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SECTION 1 – General Information

SECTION 2 – Your Top Priorities, Weight, Cravings & Metabolism

SECTION 3 – Energy, Focus & Mood

SECTION 4 – Recovery, Pain & Inflammation

SECTION 5 – Sleep, Immune & Detox

SECTION 6 – Healthy Aging, Appearance & Longevity

SECTION 7 – Microdosing Fit Check

SECTION 8 – Medical History & Current Health

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