Patient Form

Mindform Personalized GLP-1 Therapy Preparation

Please Complete Your Diet & Activity Questionnaire

We are excited to work with you as you begin your GLP-1 therapy journey. To ensure your diet and exercise plan is tailored specifically to your needs, preferences, and lifestyle, pleasecomplete the questionnaire below.

Your detailed responses will help our medical team and registered dietitian create a personalized approach that supports your health and wellness goals. Please answer each question as thoroughly as possible.

Section 1: Personal Information

Section 2: Medical and Health Background

Section 3: Current Diet and Eating Habits

Please describe your typical daily eating pattern. If possible, complete a 3-day food diary (including one weekend day) to provide a detailed record of what you eat and drink each day.

Meal Time: Foods & Drinks Consumed


Section 4: Food Preferences and Restrictions

Section 5: Diet Quality Assessment

Please rate your agreement with the following statements on a scale of 1 (Never) to 5 (Always)











Section 6: Physical Activity and Lifestyle



Average duration per session (minutes)




Section 7: Lifestyle and Motivation


Section 8: Additional Comments

Is there anything else you would like your
medical provider or dietitian to know about your diet, activity, or lifestyle?

Instructions for 3-Day Food Diary

Please record everything you eat and drink for 3 consecutive days (including one weekend day). Include portion sizes and preparation methods. Try not to change your usual eating habits—just capture your typical intake.

Thank you for taking the time to complete
this questionnaire. Your detailed responses will help us create a plan truly
personalized to your needs and goals.

Please reply to this email with your
answers, or print and bring your completed questionnaire to your next
appointment.