BWell Survey

Name(Required)

Email(Required)

What is your age range?

Under 30

30-45

46-60

60+

Biological Sex

Male

Female

Do you currently have health insurance?

Yes

No/Prefer Cash Pay

Which of the following "Root Cause" symptoms do you experience regularly? (Select all that apply)

Chronic fatigue or low afternoon energy

Difficulty concentrating or ”Brain fog”

Frequent digestive issues or bloating

Unexplained aches or systemic inflammation

How would you describe your current energy and recovery levels? (Select all that apply)

I feel chronically dehydrated or rarely drink enough water.

I feel ”run down” or catch colds easily.

I experience frequent “brain fog” or mental fatigue.

I’m an athlete/active person looking for faster post-workout recovery.

I am interested in “biological age reversal” and cellular health.

What is your primary "Quick Fix" goal?

Instant rehydration and vitamin replenishment.

A massive boost in mental clarity and cognitive focus.

Immune system support to stay healthy year-round.

How would you rate your cardiovascular awareness?

I have a family history of heart disease/stroke.

I am concerned about my cholesterol or blood pressure.

I want to proactively clear arterial plaque and improve circulation.

Do you suffer from seasonal allergies, dust, or pet dander?

Yes, and over-the-counter meds don’t provide enough relief.

Regarding your weight and metabolism, which best describes you?

I have ”stubborn” weight that won’t budge despite diet and exercise.

I want a medically supervised plan to lose 20+ lbs safely.

My weight is fine, but I want to optimize my body composition.

What are your primary aesthetic goals? (Select all that apply)

Reduce fine lines and wrinkles

Improve skin texture, scarring, or ”glow”

Address thinning hair or receding hairline

If you are over 30, have you noticed any of the following?

Decreased libido or sexual vitality

Loss of muscle mass despite working out

Increased irritability or mood swings

How is your physical recovery?

Slow recovery after workouts or injury.

Chronic joint or tissue pain.

I want to explore ”bio-hacking” tools like Peptides or Cell Therapy.