Your Personalized GLP-1 Lifestyle Plan Starts Here
This comprehensive intake helps us build a nutrition, exercise, and side-effect management plan tailored specifically to your body, your goals, and your GLP-1 journey.
🍴
Custom Nutrition
Meal plans designed around your preferences, allergies, and GLP-1 effects.
🏋
Personalized Exercise
Workouts matched to your fitness level, schedule, and goals.
💡
Side Effect Management
Strategies to minimize discomfort and maximize your results.
🔒 Estimated time: 15-20 minutes. Your information is kept strictly confidential.
Contact Information
Let's start with the basics.
Female
Male
ET
CT
MT
PT
Other
Friend
Social Media
Google
Provider
Other
Body Composition & Health Metrics
Help us understand your body and weight history.
Under 6 months
6-12 months
1-3 years
3+ years
0
1-2
3-5
5+
Calorie Restriction
Keto
Intermittent Fasting
Weight Watchers
Medication
Surgery
Exercise Only
Meal Delivery
App-Based
Other
Your GLP-1 Journey
Tell us where you are with GLP-1 medication.
💊 Currently Taking a GLP-1
I'm already on a GLP-1 medication
🌱 Starting Soon / Not Yet Started
I've been prescribed but haven't started yet
Tirzepatide
Semaglutide
Retatrutide
Other
Under 1 month
1-3 months
3-6 months
6-12 months
12+ months
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Under 10 lbs
10-25 lbs
25-50 lbs
50+ lbs
Unsure
Nausea
Vomiting
Constipation
Diarrhea
Appetite Loss
Fatigue
Hair Thinning
Headaches
Acid Reflux
Injection Site Reaction
None
None
Mild
Moderate
Severe
Injection Day
Day After
2-3 Days After
Throughout Week
Varies
Tirzepatide
Semaglutide
Retatrutide
Unsure
Other
Nausea
Weight Regain
Cost
Needles
Drug Interactions
Effectiveness
Muscle Loss
Hair Loss
None
Very Familiar
Somewhat
Not Very
Completely New
Nutrition & Diet
Tell us about your eating habits and preferences.
Beginner
Intermediate
Advanced
Chef-Level
Poor
Fair
Good
Excellent
1
2
3
4+
Under 50g
50-100g
100-150g
150g+
Unsure
Minimal
Some
Good Amount
Lots
Hydration & Digestion
Your hydration and digestive health matters.
Under 50 oz
50-64 oz
64-80 oz
80+ oz
None
1 cup
2-3 cups
4+ cups
Regular
Sometimes Irregular
Rarely Regular
Constipated
Never
Sometimes
Often
Always
None
1-3 drinks
4-7 drinks
8+ drinks
Never
Former
Occasional
Daily
Exercise & Activity
Help us design your ideal movement plan.
None
1-2 days
3-4 days
5+ days
Never
Occasionally
Frequently
Daily
Under 3,000
3,000-7,000
7,000-10,000
10,000+
Morning
Midday
Evening
Varies
Home
Gym
Outdoor
Mix
15-30 min
30-45 min
45-60 min
90+ min
Sleep
Quality rest is essential to your results.
Under 5
5-6
6-7
7-8
8+
Poor
Fair
Good
Excellent
Yes
No
Unsure
Exhausted
Groggy
Okay
Energized
Stress & Mental Health
Your mental wellness is part of the picture.
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
Never
Mild
Moderate
Severe
Never
Rarely
Sometimes
Often
1
2
3
4
5
6
7
8
9
10
Lifestyle & Environment
Your daily environment shapes your plan.
9-to-5
Shift Work
Flexible
Stay-at-Home
Retired
Sedentary
Light
Moderate
Heavy
Rarely
Monthly
Weekly
Constant
Just Me
Partner
Family
Cook for Others Daily
None
Some
Moderate
Strong
Rarely
Sometimes
Frequently
Very Frequently
Goals & Motivation
Understanding your why powers your plan.
Under 25 lbs
25-50 lbs
50-100 lbs
100+ lbs
3 months
6 months
1 year
No rush
1
2
3
4
5
6
7
8
9
10
Medical History Detail
This helps us build a safe, effective plan.
Yes, within 3 months
Yes, within 6 months
Yes, within 12 months
No
Yes
No
Unsure
Yes
No
Unsure
Type 1
Type 2
Prediabetes
No
Normal
Elevated
High
Medicated
Unsure
Normal
Elevated
Medicated
Unsure
Plan Preferences & Additional Info
Almost done! Just a few more details.
PDF
App
Both
Email
SMS / Text
App
Phone Call
Morning
Afternoon
Evening
Anytime
What happens next?
Once you submit, our team will review your intake and build your personalized GLP-1 lifestyle plan. Expect your plan within 3-5 business days.
🎉
Thank You, !
Your GLP-1 Lifestyle Plan intake has been submitted successfully. Our team will build your personalized plan within 3-5 business days.
What Happens Next
Our team reviews your complete intake profile
We build your personalized nutrition plan around your GLP-1 journey
Your custom exercise program is designed for your level and goals
Side effect management strategies are tailored to your experience
Your complete plan is delivered via your preferred method
✉ 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.