Appointment - Action Wellness

Lets find right path
to your success

Demographics

First thing first,
Whats your name

Your Name

Nice to meet you , We're a team of
clinical experts, coaches, and folks who care.

Demographics

What's your date of birth?

Date / Time

Demographics

Preferred Pronoun

He
She
Transgender Man
Transgender Woman
Non binary or non confirming
Another Identity
Decline to answer

Demographics

Gender of birth

Gender of Birth

Male
Female

Demographics

Can we get your phone number?

We will this to follow up if we need to

Phone

Demographics

Please enter your email so we can save your progress.

We will this to follow up if we need to

Email *

Obesity is linked to numerous health conditions. The CDC cites that people with obesity are at increased risk for type 2 diabetes, high blood pressure, heart disease, stroke, certain types of cancer, sleep apnea, osteoarthritis, and kidney disease, among other health issues.

Family Medical History

Does anyone in your immediate family(i.e. parents, grandparents, siblings) have a history of the following:

(select all that apply)

Family History

Heart Disease
Obesity
High Blood Pressure
High Cholesterol
Thyroid disease
Diabetes
Pre-diabetes
Multiple Endocrine Neoplasia Type 2
Medullary Thyroid Cancer

Patient Medical Information

Do you have any Allergies?

Type your allergies ( If any )

Patient Medical Information

We want to know about your Personal Medical History:

(select all that apply)

We want o know about your Personal Medical History:

Obesity
High Blood Pressure
High Cholesterol
Heart Disease
Liver Disease
Kidney problems
Gallbladder problems
Diabetes
Pre-diabetes
Cancer
Thyroid disease
Hormonal imbalance
Multiple Endocrine Neoplasia Type 2
Medullary Thyroid Cancer
Pancreatitis
Bowel Disease
Eating disorder
Gastric sleeve/bypass
Malabsorption/digestive problems
Alcoholism
Spine or Joint pain
Nerve Pain

Checkboxes

I understand weight loss treatment may interfere with a healthy pregnancy and fetal development. I will inform Action Wellness NP in Family Health PLLC if I become pregnant or plan to begin trying to conceive.

As of 2019, the CDC reported that the age-adjusted prevalence of obesity in adults was 42.4%, with no significant difference between men and women. This marked the first time the national rate has passed the 40% mark.

Physical Measurements

What is your height?

Feet

Inches

Physical Measurements

What is your current weight?

Weight in lbs

Physical Measurements

Waist Circumference

(Optional, if patient knows)

Waist Circumference

Diet and Exercise History

Select the diet and exercise programs you have tried in the past.

(select all that apply)

Options to select diet and exercise programs patient tried in the past

Keto
Intermittent Fasting
Low Carb
Calorie restriction
Weight Watchers
Nutritionist
Cross Fit
HIIT
Home-based program
Orange Theory
Personal Trainer
Other

Patient Motivation

What is your motivation level to make lifestyle changes, improve health and lose weight?

(select one)

Options to select diet and exercise programs patient tried in the past

Extremely motivated! I’’m ready to start now.
I’m motivated, and need a push in the right direction.
I know I should, but still hesitant.

Goals and Symptoms

What is your goal weight?

Let's work together to get you closer to your goal weight!

Weight in lbs

Goals and Symptoms

Motivating factors

(select all that apply)

Motivating factors

Improve my health
Improve my mood
Improve my energy levels
Fit better in my clothes
Increase my confidence
For my family
People have encouraged me to try

Goals and Symptoms

Have you recently experienced any of the following:

(select all that apply)

Have you recently experienced any of the following:

Headaches
Dizziness
Fatigue
Night Sweats
Weight change (>10 pounds within a year)
Feeling too hot or cold
Excessive Perspiration
Sugar Cravings
Excessive Thirst or Hunger
Blood Sugar Irregularities
Heart Palpitations
Nausea
Vomiting
Diarrhea
Constipation
Depression

For Patients on Medication Path

Which describes how familiar you are with GLP-1 medications (commonly known brands include: Ozempic®, Wegovy®, Mounjaro®, Saxenda®)

I am interested in GLP-1s, but open to other medications as well
I strongly prefer to use a GLP-1
I prefer not to use GLP-1s, but would consider other medications
I have never heard of these GLP-1 medications

Note

Let’s Personalize Your Journey Together
Based on the information you’ve shared, you may not be a candidate for certain weight loss medications—like GLP-1s—due to your medical history. But don’t worry, this doesn’t mean you’re out of options! Our approach is always individualized, and we offer a wide range of alternatives that can still help you safely and effectively reach your wellness goals.
Let’s schedule a consultation to discuss your unique needs and build a plan that works with your body, not against it. We’re here to support you every step of the way.

✨ Your wellness path is still wide open—we just need to take the right route for you.

Note

Wellness is More Than a Number
Your results show that your BMI (body mass index) may be below the threshold for weight loss medications—but that doesn’t mean we can’t help you optimize your health! Our comprehensive Wellness Program is designed just for you. We focus on:
• Vitamins, minerals, and targeted supplements
• One-on-one coaching and behavioral therapy
• Sustainable nutrition and exercise planning
• Personalized support to help you feel your best

Let’s build a stronger, more energized you—inside and out.
💫 Wellness starts with intention. Let’s make yours a reality.

Note

You’re a Great Candidate—Let’s Get Started!
Based on your quiz responses, you appear to be a strong candidate for weight loss treatment! We’re so excited to help you feel empowered, energized, and in control of your journey.
Our program offers:
• Medication options tailored to your health
• Personalized nutrition and fitness guidance
• Supportive coaching and lifestyle recommendations
• Ongoing follow-up and real human connection

🎯 You’ve taken the first step—now let’s take the next one together.
Book your consultation to create a plan that works with you and for you.

Lets find right path to your success

Demographics

First thing first, Whats your name

Nice to meet you , We're a team of clinical experts, coaches, and folks who care.

Demographics

What's your date of birth?

Demographics

Preferred Pronoun

Demographics

Gender of birth

Demographics

Can we get your phone number?

We will this to follow up if we need to

Demographics

Please enter your email so we can save your progress.

We will this to follow up if we need to

Obesity is linked to numerous health conditions. The CDC cites that people with obesity are at increased risk for type 2 diabetes, high blood pressure, heart disease, stroke, certain types of cancer, sleep apnea, osteoarthritis, and kidney disease, among other health issues.

Family Medical History

Does anyone in your immediate family(i.e. parents, grandparents, siblings) have a history of the following:

(select all that apply)

Patient Medical Information

Do you have any Allergies?

Patient Medical Information

We want to know about your Personal Medical History:

(select all that apply)

As of 2019, the CDC reported that the age-adjusted prevalence of obesity in adults was 42.4%, with no significant difference between men and women. This marked the first time the national rate has passed the 40% mark.

Physical Measurements

What is your height?

Physical Measurements

What is your current weight?

Physical Measurements

Waist Circumference

(Optional, if patient knows)

Diet and Exercise History

Select the diet and exercise programs you have tried in the past.

(select all that apply)

Patient Motivation

What is your motivation level to make lifestyle changes, improve health and lose weight?

(select one)

Goals and Symptoms

What is your goal weight?

Let's work together to get you closer to your goal weight!

Goals and Symptoms

Motivating factors

(select all that apply)

Goals and Symptoms

Have you recently experienced any of the following:

(select all that apply)

For Patients on Medication Path

Which describes how familiar you are with GLP-1 medications (commonly known brands include: Ozempic®, Wegovy®, Mounjaro®, Saxenda®)

Note

Note

Let’s build a stronger, more energized you—inside and out. 💫 Wellness starts with intention. Let’s make yours a reality.

Note

Services

Supplements

Resources

Lets find right path
to your success

First thing first,
Whats your name

Nice to meet you , We're a team of
clinical experts, coaches, and folks who care.

Let’s build a stronger, more energized you—inside and out.
💫 Wellness starts with intention. Let’s make yours a reality.