Personalized Wellness Plan | Rx Weight Loss & Wellness

The Rx Smarter Way To Fat Loss

A Metabolism-First Approach to Lasting Transformation

Unlock a revolutionary fat loss system rooted in biological precision. The Rx S.M.A.R.T.E.R. Way combines strategic movement, ancestral nutrition, and targeted micronutrient support—including Vitamin A, copper, magnesium, iodine, and marine sea plankton—to reactivate your metabolism and restore hormonal balance.

Designed to be both sustainable and science-based, this plan is more than a diet—it’s your prescription for long-term vitality and fat loss success.

Take 2 minutes to complete your intake form. A physician will review your responses and email you a custom exercise & diet plan within 24 hours — tailored to your goals, lifestyle, and current health.

A. Basic Information

Full Name *

Email *

Age *

Sex *

Select...

Male
Female
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Current Weight (lbs) *

Height *

Goal Weight (lbs) *

B. Medical & Medication

Do you have any medical conditions? *

Are you currently taking any medications? (please list including dosage, purpose, and length of time on the medication) *

C. Nutrition & Medication

Current Eating Habits *

Daily Protein Intake *

Select...

Low (< 75g/day)
Medium (75g-130g/day)
High (130g-220g+/day)
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Food Tracking *

Select...

Yes
No
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If yes, how do you track your food?

Allergies or Intolerances *

Daily Water Intake *

D. Exercise & Activity

Current Exercise Routine *

Do you excercise?

Yes
No
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How would you describe your current fitness level? *

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Beginner (just getting started or returning after a long break)
Intermediate (work out consistently and have a basic level of strength and endurance)
Advanced (train regularly with a high level of intensity and experience)
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How often do you exercise (per week)?

What type of exercise do you do?

How intense are your workouts?

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Light
Moderate
Intense
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Do you have access to a gym or home exercise equipment?

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Gym access
Home equipment
Neither
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How active is your daily life outside of workouts?

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Sendentary
Lightly Active
Active
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E. Supplementation

Current Supplements *

Would you be open to adding supplements to support (select all that apply): *

Fat Loss

Muscle Retention

Energy

Gut Health

Appetite Control

Sleep

F. Lifestyle & Habits

How would you rate your sleep quality? *

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Poor
Fair
Good
Excellent
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Sleep Duration *

Stress Level *

Occupation *

Do you have a strong support system? *

Select...

Yes
No
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Past Weight Loss Attempts *

What is your goal?

Select...

Rapid Fat Loss
Slow Fat Loss
Maintain Fat and Muscle Gain
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Primary Motivation *

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