Client Wellness Program Inquiry

Complete the questions below to help us understand your goals, lifestyle, and current challenges. Your responses allow our team to recommend programs that may support improvements in metabolism, energy, recovery, and overall wellness.

This assessment is for informational and wellness planning purposes only and does not provide medical diagnosis or treatment.

After submission, one of our GLP-1 and peptide certified consultants will review your responses and email you with personalized program recommendations, options, and pricing tailored specifically to you.

First name

Last name

Phone number

Email

Address

Primary Goals - What are the biggest changes you want right now?

Lose significant body fat

Improve appetite control and metabolic health

Increase energy and stamina

Improve recovery from workouts or injuries

Improve focus, mood, or mental clarity

Slow aging and improve skin health

General longevity and wellness

In the next 6–12 months, what outcomes matter most to you? (Select up to 3)

Weight & Metabolism - How much weight would you ideally like to lose?

How often do you experience emotional eating, nighttime snacking, or strong food cravings?

Never

Sometimes

Often

Almost daily

Have you ever used GLP-1 medications such as semaglutide or tirzepatide?

No

Yes and they worked well

Yes but I had side effects

Yes but the weight returned after stopping

What GLP-1 Medication were you on?

What was your last used dose (in mg) that you took?

When was the last time you took this dose?

How would you describe your overall stamina?

Excellent

Good

Average

Poor

Recovery & Inflammation - How quickly do you recover from workouts or physical activity?

Very quickly

Normal recovery

Slower than I would like

Very slow recovery

Do you experience joint pain, tendon issues, or lingering injuries?

No

Occasionally

Frequently

Constantly

Do you currently have any injuries that limit your activity?

No

Minor injuries

Moderate injuries

Significant injuries

List current injuries or chronic issues

How would you describe your mental focus and productivity?

Excellent

Good

Average

Poor

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

Rarely

Sometimes

Often

Almost constantly

Longevity & Aging -- How concerned are you about aging-related changes such as strength, metabolism, or stamina?

Not concerned

Slightly concerned

Moderately concerned

Very concerned

Do you notice signs such as slower healing, thinning hair, dull skin, or loss of skin elasticity?

Not at all

Slightly

Moderately

Significantly

How interested are you in longevity and healthy aging programs?

Not interested

Somewhat interested

Very interested

Lifestyle Factors - How stressful would you say your lifestyle currently is?

Low stress

Moderate stress

High stress

Extremely high stress

How often are you exposed to alcohol, travel stress, environmental toxins, or heavy work demands?

Rarely

Sometimes

Often

Very frequently

Health Screening - Have you ever been told by a medical provider that you should avoid GLP-1 medications?

No

Yes

Not sure

Other

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

Are you currently pregnant, breastfeeding, or planning pregnancy in the next 6 months?

No

Pregnant

Breastfeeding

Planning pregnancy

Which of these best describes what you want help with most right now?

Permission to Contact

I consent to Sunny Shores contacting me by phone, text, or email regarding the information I provided and the wellness programs, services, or consultation options that may be appropriate for me. Your information will never be sold or shared with third parties.

Privacy & HIPAA Acknowledgment

I understand that the information submitted in this form may include personal health information and will be used solely for wellness consultation and program eligibility review. I consent to Sunny Shores securely sharing relevant information with licensed medical providers when necessary to determine eligibility for physician-guided programs. All information will be handled confidentially in accordance with privacy and HIPAA standards where applicable.

Your privacy is important to us. All personal and health information is handled securely and only used to help determine appropriate wellness options.

Medical & Program Disclaimer

The information provided in this form is used solely to help guide wellness consultations and determine potential eligibility for physician-guided programs. Submission of this form does not establish a patient-provider relationship and does not guarantee that any medication or treatment will be recommended or prescribed.

All prescribing decisions, if applicable, are made exclusively by licensed medical providers following review of your health history and consultation.