Total Transformation Intake

📌 Please complete all sections of this form.

IMPORTANT:

We use your answers to build your personalized care plan.
Missing information slows down our ability to assist you.
This may delay or limit your treatment options.
Take your time, be thorough, and don't leave anything blank unless it doesn't apply.
(Yes, we read every word.)
Your results will thank you.

Thank you! Your Total Transformation intake has been submitted.

Check your email for complete details about the Total Transformation program.

Ready to Schedule Your Total Transformation Consultation?

Choose your preferred consultation type:

Or call us to schedule:

(248) 792-6570

Back to Homepage

Section 1: Basic Information

First Name *

Last Name *

Date of Birth *

Gender at Birth

Mobile Phone *

Email *

Street Address

Apartment/Suite/Floor (if applicable)

City

State

Zip Code

Preferred Clinic Location

Section 2: Emergency Contact

Emergency Contact Name

Emergency Contact Phone

Section 3: Work & Goals

Occupation

Company Name

Typical Work Schedule (Days and times)

What are your overall goals for this program?

What is your primary reason for joining this program?

Section 4: Motivation & Mindset

Have you ever been given a structured plan (diet, exercise, lifestyle) before?

Yes No

Please describe your previous structured plans:

What makes having a plan helpful to you?

What motivates you (examples: family, health, appearance, energy)?

What has caused you to abandon plans in the past?

What do you expect from this program?

Why are you motivated to make changes now?

What are your biggest obstacles or challenges?

How will you measure your progress?

What timeline do you expect for seeing results?

Section 5: Communication Preferences

Preferred Communication Method

How often would you like to check in?

Section 6: Health History

What specific areas would you like to focus on (examples: weight loss, muscle gain, energy, sleep, stress management)?

What level of support do you expect from us? (0 = None, I'm self-supported | 10 = Extreme, I'm very needy)

Do you have any chronic conditions?

Yes No

Please describe your chronic conditions:

Have you had any surgeries or hospitalizations? Please list with dates.

How would you rate your overall health?

Current stress level (1-10) (1 = no stress, 10 = extreme stress)

Do you experience any pain or discomfort?

Yes No

Please describe location, frequency, and severity:

Pregnancy Status

Do you have recent bloodwork available?

If yes, please upload your bloodwork (PDF or image)

Section 7: Medications, Supplements & Peptides

Please list all medical diagnoses

Please list all medications (name, dosage, frequency)

Please list all vitamins, supplements, and herbal remedies

Have you used peptides in the past or currently? If yes, please list.

Section 8: Sleep & Recovery

What time do you typically wake up?

What time do you typically go to bed?

Average hours of sleep per night

How many times do you wake up per night?

How would you rate your sleep quality?

Section 9: Lifestyle Habits

Do you smoke or use tobacco?

How often do you consume alcohol?

Describe your typical morning routine

Describe your typical evening routine

Do you prefer morning or evening showers?

Section 10: Nutrition

Morning commute time

Evening commute time

Describe your typical daily diet (breakfast, lunch, dinner, snacks)

Preferred Diet

If Other, please specify

What are your favorite foods?

What foods do you dislike or avoid?

Are there any foods that don't sit well with you?

Do you use any digestive aids (probiotics, enzymes, etc.)?

Do you experience any symptoms related to food (bloating, gas, reflux, etc.)?

Do you have any food allergies or intolerances?

How would you rate your current diet?

Daily water intake

What challenges do you face with food preparation?

How many meals do you eat per day?

Meal prep style

How often do you eat out or order in? (per week)

Section 11: Fitness

Describe your current exercise routine

What types of exercise do you enjoy?

What exercises do you dislike but will do?

What exercises do you dislike and won't do?

Do you have any physical limitations or injuries?

Current fitness level

Where do you prefer to work out? (gym, home, outdoors, etc.) Please include any equipment available.

Are there days you absolutely cannot work out?

What are your preferred rest days?

Preferred workout time

Secondary workout time (if applicable)

What is your exercise history? (sports, activities, etc.)

What barriers prevent you from exercising regularly?

What do you do for recovery? (stretching, massage, etc.)

Section 12: Hormone and Metabolic Function

Have you experienced any of the following in the last 3 months? (fatigue, weight changes, mood changes, hot flashes, night sweats, irregular periods, low libido, etc.)

Yes No

Please describe your symptoms:

Are you currently on any hormone therapy or birth control?

Yes No

Please describe:

Do you suspect you may have thyroid or adrenal imbalances?

Yes No

Please describe:

Section 13: Mental & Emotional Well-being

How would you describe your current mental and emotional health?

What are the most significant stressors in your life?

Do you have a history of anxiety, depression, or other mental health conditions?

Yes No

Please describe:

What do you currently do to manage stress?

What triggers your stress the most?

Describe your support system (family, friends, community)

How open are you to trying new stress management techniques?

Section 14: Logistics

Are there any financial constraints we should be aware of?

Yes No

Please describe:

Do you have any accessibility or special needs?

Yes No

Please describe:

Section 15: Anything Else

Is there anything else you'd like us to know?

Section 16: Signature

By typing your full legal name below, you certify that all information provided in this form is true and accurate to the best of your knowledge. You understand that this information will be used to create your personalized Total Transformation plan.

You acknowledge that the Total Transformation program is designed to support your health and wellness goals but is not a substitute for medical care. You agree to consult with your healthcare provider before making significant changes to your diet, exercise, or lifestyle.

Marketing Communications

By signing up with our services, you consent to receive marketing communications from us via email and /SMS. These messages may include updates, promotions, and other information relevant to your engagement with us. You can opt out at any time by replying "STOP" to any SMS message or by clicking the unsubscribe link in our emails.

I consent to receive marketing communications

Full Legal Name (This acts as your electronic signature) *

Submitting your application...

BE Well Total Transformation 12 WeekInitial Intake

IMPORTANT:

Thank you! Your Total Transformation intake has been submitted.

Ready to Schedule Your Total Transformation Consultation?

Section 1: Basic Information

Section 2: Emergency Contact

Section 3: Work & Goals

Section 4: Motivation & Mindset

Section 5: Communication Preferences

Section 6: Health History

Section 7: Medications, Supplements & Peptides

Section 8: Sleep & Recovery

Section 9: Lifestyle Habits

Section 10: Nutrition

Section 11: Fitness

Section 12: Hormone and Metabolic Function

Section 13: Mental & Emotional Well-being

Section 14: Logistics

Section 15: Anything Else

Section 16: Signature

Marketing Communications

BE Well Total Transformation 12 Week
Initial Intake