Sleep and Metabolic Program Questionnaire

Step 1 of 14 - Goal

What are you looking for support with? (Select all that apply)(Required)

Weight loss

Better sleep

Low energy

Snoring / possible sleep apnea

General health improvement

Appetite/craving control

Have you tried to lose weight before?(Required)

Yes

What has been most challenging? (Select all that apply)

Cravings

Portion control

Low energy

Lack of results

Staying consistent

Height - Feet(Required)

Height - Inches

Weight (lbs)(Required)

Your BMI(Required)

Thanks for your responses. At this time, this program may not be the best fit for your needs.

We recommend speaking with your primary care provider or a specialist for more appropriate support.

How would you describe your sleep? (Select all that apply)(Required)

I sleep well and feel rested

I have trouble falling asleep

I wake frequently during the night

I wake up tired

I snore or have been told I stop breathing

Have you ever had a sleep study?(Required)

Yes

Not sure

What type of sleep study did you have?

At-home sleep test

In-lab sleep study

Not sure

What were the results?

Diagnosed with moderate/severe sleep apnea

Mild sleep apnea

Not sure

Thanks for your responses. At this time, this program may not be the best fit for your needs.

We recommend speaking with your primary care provider or a specialist for more appropriate support.

Are you currently using a CPAP or other treatment?

Yes

Based on your answers, your sleep may be impacting your health and energy.

We recommend a Home Sleep Apnea Test (HSAT):

Done at home
Simple and non-invasive
Helps identify sleep apnea

How would you like to proceed?(Required)

Continue to book NP GLP-1 consultation

Yes, I’m interested in sleep testing

How would you describe your eating habits?

I eat regularly (2–3 meals/day)

I skip meals

I snack frequently

My eating is inconsistent

When are your cravings strongest?

Morning

Afternoon

Evening

Late night

How often do you exercise?

Rarely

1–2x/week

3–5x/week

Daily

Do you have any of the following? (Select all that apply)

Type 2 diabetes

Thyroid condition

High blood pressure

High cholesterol

None of the above

Do any of the following apply to you? (Select all that apply)

I am pregnant or breastfeeding

I have a history of pancreatitis

I have been diagnosed with an eating disorder (past or current)

I have had significant unexplained weight loss recently

I have a personal or family history of medullary thyroid cancer or MEN2

None of the above

Thanks for your responses. At this time, this program may not be the best fit for your needs.

We recommend speaking with your primary care provider or a specialist for more appropriate support.

This program includes medical care with a Nurse Practitioner, nutrition support with a Registered Dietitian, sleep assessment and support, and medication if appropriate. Are you comfortable with this approach?

Yes

I'd like more information

This is a structured medical program with ongoing support (not a one-time prescription). Are you comfortable with this approach?

Yes

I'd like more information

What are you hoping to achieve? (Select all that apply)

Sustainable weight loss

Appetite/craving control

Better sleep and energy

Quick results

Are you open to ongoing follow-up and support over several months?

Yes

Not Sure

How ready are you to make changes right now?

What would you like to do next?

Book NP consultation

Speak with team first