WMC (Tier 1)

Member Health History

Welcome to the Wellness Mastery Circle!

This brief health history form helps us get to know you a little better so we can guide you through resources, education, and challenges that best support your wellness goals. While Tier 1 members do not receive 1:1 coaching, the information you provide here allows our team to make sure your experience inside the membership feels personal and meaningful. Please take a few minutes to answer honestly—there are no wrong answers!

Today's Date: *

First Name *

Last Name *

Date of birth *

Phone *

Email *

Preferred Method of Contact: *

Lifestyle & Health Snapshot

What are your top 2–3 health or wellness goals right now? *

On average, how many hours of sleep do you get per night? *

Less than 5

5–6

7–8

Do you take any supplements regularly? If yes, please list them. *

Current Health Status

Do you have any current medical diagnoses? *

Do you take any medications regularly? (If yes, please list them) *

Any food or medication allergies we should be aware of? *

Mindset & Readiness

How committed are you to making small, sustainable changes? *

Just starting out

Pretty motivated

All in and ready!

Is there anything else you’d like us to know to support you better? *

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.