Program Interest Form | rootedinhealth.life

Full Name: Email:

Date of birth: Occupation:

Goal Weight: lbs Current Weight: lbs

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

Not at all Slightly Neutral Important Very Important

In the next 6–12 months, what are your top 3 outcomes? (check up to 3)

Current Activity Level:

Low Moderate High

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

Not at all Slightly Moderately Significantly Severely

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

Never Rarely Sometimes Often Always

How much do you struggle with (overall) constant thoughts about food / “food noise”?

Not at all Slightly Moderately Significantly Severely

How much do you struggle with (overall) nighttime snacking?

Not at all Slightly Moderately Significantly Severely

How much do you struggle with (overall) overeating on weekends or social events?

Not at all Slightly Moderately Significantly Severely

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

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

Do you experience chronic fatigue, low stamina, or frequent “energy crashes”?

Never Rarely Sometimes Often Always

How often do you struggle with brain fog, poor focus, or forgetfulness?

Never Rarely Sometimes Often Always

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

Never Rarely Sometimes Often Always

“I recover slower than I should from workouts, soreness, or injuries.”

Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree

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

Never Rarely Sometimes Often Always

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

No Yes – mild Yes – moderate Yes – significant

How often do you struggle with poor sleep, frequent waking, or unrefreshing sleep?

Never Rarely Sometimes Often Always

Do you feel like you get sick easily or take a long time to bounce back from illness?

Never Rarely Sometimes Often Always

Are you regularly exposed to alcohol, smoking, travel, or environmental toxins (chemicals, pollution, etc.)?

Never Rarely Sometimes Often Always

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

Not concerned Slightly Neutral Concerned Very concerned

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

Not at all Slightly Moderately Significantly Severely

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

Not interested Somewhat interested Very interested Extremely interested

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

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

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

Client Health & Goals Assessment

High-Level Medical History