Mens questionaire | PowerSource Rx

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Are you experiencing hair thinning/loss? If Yes, how long?

What skin concerns do you have? (acne, wrinkles, dullness, sun damage, etc.)

Do you have issues with energy levels, mood, or motivation?

Do you have any concerns about your sexual health or function? (Yes/No) If yes, explain severity shortly.

Do you experience chronic pain or inflammation anywhere in your body? (Yes/No) If yes, for how long and where?

Do you have any current injuries that aren't healing properly? (Yes/No If yes, explain.

Which fitness goal represents your needs best?

What would you say your current body type is?

What is your level of fitness?

Beginner( rarely exercise or am just starting out.)

Lightly Active (I walk or do light activity a few times a week.)

Moderately Active (I exercise 2–4 times per week with moderate effort.)

Very Active (I work out 4–6 times per week and stay consistently active.)

Athlete/Fitness Enthusiast (I train intensely, follow a routine, and focus on performance.)

Have you been prescribed any TRT, Peptides or are you on any Sarms, Creatine ect.?

How committed are you to making lifestyle changes? (1-10 scale)

What is your budget range for wellness treatments per month?

How did you hear about our services, and what attracted you to peptide/wellness therapy?