Client Intake form

This assessment is a tool for Sunny Shores to help us understand your goals and challenges, it helps us to suggest which medication program(s) to apply your for. This is not a medical intake, diagnosis, prescription or a guarantee that any medication will be prescribed.

All prescribing decisions are made solely by independent licensed medical providers.

Your Top Priorities

Weight, Cravings & Metabolism

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

How much do you struggle with (overall) Constant thoughts about food/ food noise, nighttime snacking, and/or overeating on weekends or social events? *

Have you ever lost weight and then regained it within the last 2-3 years? *

No Yes 5-10 pounds Yes 10-25 pounds Yes 25 pounds +

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

Energy, Mood & Focus

Recovery, Pain & Inflammation

Sleep, Immunity & Detox

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

Healthy Aging, Appearance & Longevity

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

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

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

Not interested Somewhat interested Very Interested Extremely interested

Microdosing Fit Check

Describe your current weight situation? *

I want to lose 20+ pounds I want to lose 10-20 pounds 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? *

Check all that apply: Which sounds like you? *

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

High-Level Medical History

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

No YES -- Explain

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

YOUR CART

Client Health & Goals Assessment

Your Top Priorities

Weight, Cravings & Metabolism

Energy, Mood & Focus

Recovery, Pain & Inflammation

Sleep, Immunity & Detox

Healthy Aging, Appearance & Longevity

Microdosing Fit Check

High-Level Medical History

YOUR CART

Client Health & Goals Assessment

Your Top Priorities

Weight, Cravings & Metabolism

Energy, Mood & Focus

Recovery, Pain & Inflammation

Sleep, Immunity & Detox

​Healthy Aging, Appearance & Longevity

Microdosing Fit Check

High-Level Medical History

Healthy Aging, Appearance & Longevity