Check Your Score

Let's Personalize your path to Real Results. Please complete the form so Dr. Wendy and her team can review your current challenges, goals, and health history before creating your

personalized plan.

Full Name *

Date of birth *

Phone *

Email *

Have you tried any weight loss programs in the past? *

Yes

What is your biggest challenge with your health? *

Lack of motivation

Struggles with diet

No time for exercise

Medical conditions

What are your top 3 health goals right now? *

Lose weight

Balance hormones

Reduce bloating

Improve energy

Sleep better

Reverse prediabetes

Which is most important to you right now?

Which of the following are you currently experiencing? check all that apply

Weight that won't budge

Belly fat

Mood swings or irritability

Fatigue or burnout

Night sweats / hot flashes

Cravings (sugar or salty foods)

Bloating or gut issues

Poor sleep

Irregular or heavy periods

Anxiety or low mood

Brain fog or forgetfulness

Other

How long have you been experiencing these issues?

Have you Had recent lab work done in the last 6 months? *

Yes

If yes, what labs? You may be asked to upload them after approval.

Are you currently taking any medications? *

Yes

If yes, please list

Do you have any medical conditions that affect your weight? *

Diabetes

Thyroid issues

High blood pressure

Other Issues not listed

None of the above

On a scale of 1-10, how committed are you to making changes for your health right now? *

Immediately (10)

Within the next month (6)

In the future, but not ready yet (3)

Not sure (1)

What is your biggest barrier or fear about reaching your goals?

Why is NOW the right time for you to do this?

Anything else you would like Dr. Wendy to know?

What type of health support are you most interested in? *

Personalized health plan with support

Meal planning & nutrition guidance

Fitness training & workout programs

Medical weight loss options

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