Questionnaire

Step 1 — Basic Info

First Name Last Name Email Phone Date of Birth State (for telehealth compliance)

Step 2 — Goals

Which best describes your main goal?

Weight loss Weight maintenance / prevent weight regain Reduce cravings / “food noise” Improve blood sugar balance / insulin resistance Reduce inflammation / bloating Improve body composition / visceral fat Improve metabolic health (cholesterol, energy, etc.) Unsure — want guidance

Step 3 — Body Metrics

Height (feet) Height (inches) Weight (lbs) BMI (auto-calculated)

Have you gained 10+ lbs in the last 12 months?

Yes No

Have you struggled to lose weight despite diet/exercise?

Yes No Not applicable

Step 4 — Medical Eligibility

Step 5 — Medication Safety

Are you currently taking a GLP-1 medication?

No Yes (Ozempic/Wegovy/Mounjaro/Zepbound/Rybelsus/other)

Are you currently taking insulin or sulfonylureas?

Yes No

Are you taking any of the following medications?

Thyroid medication Metformin Cholesterol medication Blood pressure medication ADHD stimulant medication None

Step 6 — Lifestyle & Readiness

Which best describes your relationship with food?

I feel in control I struggle with cravings / food noise I often overeat even when not hungry I experience binge eating patterns

How would you rate your current stress level?

Low Moderate High

How many days/week do you strength train or resistance train?

0 1–2 3–4 5+

Are you willing to follow guidance on hydration, protein targets, and lifestyle support?

Yes Maybe No

Step 7 — Program Match

Which describes what you want?

Full medical weight-loss program Micro-dosing (metabolic support + cravings + maintenance) Just exploring / want to talk first

Preferred service type:

Virtual consult In person consult (DeWitt/Skaneateles) Either

Your answers help us tailor the safest, most effective path and identify if micro-dosing vs. full medical weight-loss is the best fit.

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