Your Personalized GLP-1 Lifestyle Plan Starts Here
This comprehensive intake helps us build a plan tailored entirely to your body, your life, and your goals. The more detail you share, the more personalized and effective your plan will be.
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Custom Nutrition Plan & Recipes
Protein/calorie targets, meal timing, and recipes built around your preferences and GLP-1 needs
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Personalized Exercise Program
Resistance training and activity plan designed to preserve lean muscle while maximizing fat loss
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Side Effect Management & Lifestyle Optimization
Hydration, sleep, stress management, and GI support strategies tailored to your situation
🔒 Estimated time: 15-20 minutes. Your information is kept confidential and reviewed only by your Elevation Health clinical team.
Contact Information
Let's start with the basics so we can reach you and personalize your plan.
Male
Female
Address
Optional but recommended for clinical records
Body Metrics & Composition
Accurate measurements help us calculate your protein, calorie, and hydration targets precisely.
lbs
lbs
ft
in
in
Measure at navel level
in
%
Weight History
lbs
lbs
Less than 6 months
6-12 months
1-3 years
3+ years
First time
1-2 times
3-5 times
5+ times
Your GLP-1 Medication
Understanding your current or upcoming medication helps us tailor everything — from meal timing to side effect management.
💊
Currently Taking a GLP-1
I'm already on medication and want to optimize my results
🌱
Starting Soon / Considering
I haven't started yet or I'm about to begin
None yet
Under 10 lbs
10-25 lbs
25-50 lbs
50+ lbs
GLP-1 Side Effects
Why we ask: GI side effects are the #1 barrier to adequate nutrition on GLP-1 therapy. Your answers here directly shape your meal plan, eating schedule, and side-effect management recommendations.
No side effects
Mild
Moderate
Severe
Injection day
Day after
First 2-3 days
Constant
N/A
My primary care doctor
Telehealth provider
Elevation Health
Endocrinologist
Other
Very familiar — done lots of research
Somewhat — know the basics
Not very — my doctor recommended it
Brand new — just learning
Yes
No
Medical History & Medications
A complete picture helps us avoid contraindications and design a safe, effective plan.
Lab Results (Optional)
If you have recent lab work (within 6 months), sharing key values helps us fine-tune your plan. Leave blank if unavailable.
mg/dL
%
mg/dL
mg/dL
mg/dL
mg/dL
mIU/L
ng/mL
ng/dL
uIU/mL
mg/L
pg/mL
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Click to upload or drag & drop PDF, JPG, PNG (max 10MB)
Nutrition & Eating Habits
Your current relationship with food is the foundation for your personalized nutrition plan.
Poor — mostly processed / fast food
Fair — trying but inconsistent
Good — mostly whole foods
Excellent — very intentional
1 meal/day
2 meals/day
3 meals/day
4+ meals/day
Under 50g
50-100g
100-150g
150g+
Very easy
Easy
Moderate
Difficult
Very difficult
Beginner
Intermediate
Advanced
Minimal (30 mins/week)
Some (2-3 hrs/week)
Good (5+ hrs/week)
No meal prep
Occasional
Weekly (1 day)
Frequent (multiple days)
Rarely (< 1x/week)
Sometimes (1-3x/week)
Often (4-6x/week)
Most meals
Under $60
$60-100
$100-150
$150+
Hydration & Digestion
Water, GI health, and other habits that directly impact your success on GLP-1.
Under 50 oz
50-80 oz
80-100 oz
100+ oz
None
Under 100mg
100-200mg
200mg+
Constipated (< 3x/week)
Regular (5-7x/week)
Loose / frequent (7+ times)
Never
Sometimes
Often
Very frequently
None
1-3 drinks
4-7 drinks
7+ drinks
Never
Former user
Occasional
Daily
Exercise & Physical Activity
We'll design a resistance program to preserve muscle while you lose fat on GLP-1.
None
1-2x/week
3-4x/week
5+ times/week
No
Occasional (1-2x/week)
Regular (3-4x/week)
Frequent (5+ times/week)
Under 3,000
3,000-7,000
7,000-10,000
10,000+
Home
Gym / studio
Outdoor
Mix of locations
Morning
Midday
Evening
Flexible
Under 30 min
30-60 min
60-90 min
90+ min
Sedentary
Lightly active
Moderately active
Very active
No
Sometimes
Regularly
Sleep & Recovery
Sleep quality is critical for hormone balance, appetite control, and sustainable weight loss.
Under 6 hours
6-7 hours
7-8 hours
8+ hours
Poor
Fair
Good
Excellent
No
Diagnosed but don't use
Yes, using regularly
Exhausted
Groggy
Okay
Energized
Stress & Mental Wellness
Emotional and psychological factors shape your relationship with food and your ability to stick to your plan.
LowModerateVery High
Very LowModerateVery High
None
Mild
Moderate
Severe
Never
Rarely
Sometimes
Often
Very PoorFairExcellent
Daily Life & Schedule
Understanding your lifestyle helps us build a plan that actually fits your reality.
Not working
Flexible / remote
9-5 standard
Irregular / shifts
Sedentary (desk)
Light activity
Moderate activity
Very active
Never
Rarely
Monthly
Frequent (weekly+)
No
Sometimes
Often
Daily
None
Minimal
Moderate
Very strong
Minimal
Moderate
Frequent
Very frequent
Goals & Motivation
The clearer your vision, the better we can help you reach it.
Under 25 lbs
25-50 lbs
50-75 lbs
75+ lbs
Within 3 months
Within 6 months
Within 1 year
No specific timeline
Self-motivated
Coach / provider check-ins
Group / community
Family / friend support
Not committedSomewhatFully committed
Plan Preferences & Additional Info
Final touches to ensure your plan is delivered exactly how you prefer.
PDF document
App / online platform
Both
Email
Text / SMS
In-app message
Phone call
Morning
Afternoon
Evening
Anytime
Thank you for completing this comprehensive intake! Your answers will help our clinical team design a truly personalized GLP-1 Lifestyle Plan. Your PDF will be generated and you'll receive your plan within 3-5 business days.
🎉
Thank You, There!
Your intake has been successfully submitted. Our clinical team will review your information and begin building your personalized GLP-1 Lifestyle Plan right away. Your complete plan will be delivered within 3-5 business days.
What Happens Next
✓ Our team reviews your intake
✓ We build your custom nutrition plan
✓ Exercise program designed for your level
✓ Side effect strategies & lifestyle optimization
✓ You receive your complete plan
📧 One last step: If you have recent lab results, bloodwork, or any other health documentation you'd like us to review, please email them to info@elevationhealth.co with your name in the subject line. This helps us tailor your plan more precisely.