Client Health & Goals Assessment | Pure Serenity Health Spa

Personal Information

Full Name

Age & Birthday

Occupation

Current Weight

Goal Weight

Current Activity Level

Low Moderate High

Section 1 – Your Top Priorities

1. How important is it for you to improve your health and energy right now?

Not at all Slightly Neutral Important Very Important

Section 2 – Weight, Cravings & Metabolism

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

Not at all Slightly Moderately Significantly Severely

4. How often do you feel like your weight or midsection is slowly creeping up, even when you're trying?

Not at all Slightly Moderately Significantly Severely

5. How much do you struggle with (overall):

	Never	Rarely	Sometimes	Often	Always
Constant thoughts about food / "food noise"
Nighttime snacking
Overeating on weekends or social events

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

No Yes, 5–10 lbs Yes, 10–25 lbs Yes, 25+ lbs

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

No Yes – and I did well Yes – but I had side effects Yes – lost weight but gained most of it back

Section 3 – Energy, Focus & Mood

	Never	Rarely	Sometimes	Often	Always
8. Do you experience chronic fatigue, low stamina, or frequent "energy crashes"?
9. How often do you struggle with brain fog, poor focus, or forgetfulness?
10. How often do you feel stressed, overwhelmed, or mentally burned out?

Section 4 – Recovery, Pain & Inflammation

11. "I recover slower than I should from workouts, soreness, or injuries."

Not at all Slightly Moderately Significantly Severely

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

Not at all Slightly Moderately Significantly Severely

13. Have you had lingering discomfort from an old injury or surgery?

No Yes – mild Yes – moderate Yes – significant

Section 5 - Sleep, Immune & Detox

	Never	Rarely	Sometimes	Often	Always
14. How often do you struggle with poor sleep, frequent waking, or unrefreshing sleep?
15. Do you feel like you get sick easily or take a long time to bounce back from illness?
16. Are you regularly exposed to alcohol, smoking, travel, or environmental toxins?

Section 6 - Healthy Aging, Appearance & Longevity

17. How concerned are you about aging-related changes (strength, stamina, body composition)?

Not Concerned Slightly Neutral Concerned Very Concerned

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

Not at all Slightly Moderately Significantly Severely

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

Not Interested Somewhat Interested Very Interested Extremely Interested

Section 7 - Microdosing Fit Check

20. Which best describes your current weight situation?

I want to lose 20+ lbs I 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

21. 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?

Never Rarely Sometimes Often Always

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

I want gentle appetite and craving control without a high-dose protocol I'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 plan I have blood sugar / insulin resistance concerns and want extra support staying stable I'm dealing with inflammation, aches, or "puffy" weight tied to stress or hormones I'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 - High-Level Medical History

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

No

Yes

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

Type 1 diabetes Uncontrolled Type 2 diabetes History of pancreatitis History of medullary thyroid cancer or MEN2 Severe GI disease (gastroparesis, severe Crohn's, etc.) Active cancer treatment None of the above / not sure

25. Are you currently:

Pregnant Breastfeeding Planning pregnancy in the next 6 months None of the above

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

27. Current prescription medications or major supplements: