Modern Vitality Signature Program Application

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Honestly, which best describes your attitude towards healing?* This field is required.

I am open and ready for new health solutions, and I believe there is a way for me to get better.

I am jaded and burned out from trying and failing, but still optimistic there's hope.

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What motivated you to take time out of your day today and apply for the MV Signature Program?* This field is required.

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What's your name?* This field is required.

First Name

Last Name

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Your favorite Email Address?* This field is required.So that we can let you know the status of your application

example@example.com

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What's your biological gender?* This field is required.

Male

Female

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HEALTH HISTORY (CONFIDENTIAL)In this section we will take a detailed look at your health history.

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May we ask some detailed questions about your health so that we can get a clear and comprehensive understanding?* This field is required.

Yes

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Great, thank you. To begin, what is your age?* This field is required.

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What is your height?* This field is required.

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What is your current weight?* This field is required.

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Have you ever been diagnosed with Celiac's Disease?* This field is required.

YESNO

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Please list out all medications, supplements, and herbs you are currently taking* This field is required.If none, just type "none"

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Please list out all food allergies* This field is required.Are these true allergies or just sensitivities?

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Do you have other allergies? If so please explain.* This field is required.If none, just type "none"

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What was your blood pressure the last time it was checked?* This field is required.You don't have to be 100% exact here.

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What is your resting heartrate in Beats per Minute (BPM)?* This field is required.To find your resting heartrate, set a timer for 20 seconds. Feel the pulse at your wrist and count how many beats happen in 20 seconds. Then multiply that number times 3, for your "beats per minute". For example, if you feel 18 beats in 20 seconds, you would multiply 18 x 3, and the answer is 54 BPM (beats per minute)

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Please describe all relevant diagnoses you currently have, and how long you've had each one* This field is required.

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Please describe the major symptoms you regularly experience* This field is required.

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What types of pain do you regularly experience?* This field is required.Please check all that apply

Wandering Pain

Dull Aches

Sharp Stabbing

Electric/Shooting

Cramping/Spasms

Tension

Burning Pain

I don't have chronic pains

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"Ever since ____________________ I've never felt the same"* This field is required.

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What kind of weather do you prefer?* This field is required.

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Do you have a history of:* This field is required.Check all that apply

Mold Exposure

Chemical Exposure

Tick Bites

Parasites

None of these

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Have you had any major surgeries? Please describe the circumstances including approximate timeline* This field is required.

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Have you had any major car accidents? Please describe the circumstances including approximate timeline* This field is required.

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Do you have any major medical procedures or interventions coming up? If so please describe* This field is required.

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Please list out the types of health professionals you regularly see.* This field is required.For example naturopath, rheumatologist, acupuncturist, massage, etc

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METABOLISMIn this section we will get a sense of your metabolic activity

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Which of these statements is most true?* This field is required.

I remind myself to drink water throughout the day because I know it's good for me

I get thirsty and actively seek out water throughout the day

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Do you often experience dry mouth?* This field is required.

YESNO

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Which of these statements is most true?* This field is required.

I don't have much of an appetite but I eat anyway because I probably should

I get hungry and actively seek out food

I have zero appetite and don't want to eat

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Do you often experience bloating?* This field is required.

YESNO

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Are you on any specific diet plan? Please describe.* This field is required.For example: keto, atkins, whole 30, vegan, paleo, etc

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What time do you usually stop eating for the day?* This field is required.

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Please list out everything you eat in a typical day* This field is required.

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What is your favorite snack?* This field is required.

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What did you have for breakfast today?* This field is required.

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Why did you choose that number?* This field is required.

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What do you do on an average day?* This field is required.For example, going to work, exercise, running errands, socializing, cooking, resting, etc

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Do you often experience shortness of breath?* This field is required.

YESNO

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How long can you hold your breath for right now? Set a timer and let's find out.* This field is required.

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Is it more challenging for you to:* This field is required.

Lose Weight

Gain Weight

Neither

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Why did you choose that number?* This field is required.

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What do you enjoy doing for exercise/movement, and when is the last time you did it?* This field is required.For example, walking, yoga, freeweights, swimming...

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Please check all that regularly apply to you* This field is required.

My hands and feet feel cold

My body (core) feels cold

My body (core) feels hot

My head feels hot

None of these regularly apply

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Please check all that regularly apply to you* This field is required.

I rarely sweat

I sweat easily

My hands or feet get sweaty

I get sweat in my inner thighs often

None of these

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SLEEP + RECOVERYThis section will evaluate the quality of your sleep

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How important is your sleep to you? Do you make it a priority?* This field is required.

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What time do you usually go to bed?* This field is required.

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What time do you usually wake up?* This field is required.

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Do you have any recurring dreams? If so what themes are present?* This field is required.

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UROGENITAL MICROBIOMEThis section will help to determine fluid metabolism and immune activity in the lower part of the body

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Please select all that regularly apply to you:* This field is required.

Frequent or disruptive urination

Burning urination

Incomplete or dribbling urination

Clear/light yellow urine

Dark colored urine

Frothy urine

Cloudy urine

None of these apply to me

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Are you prone to:* This field is required.Please check all that apply

Yeast Infections

Jock Itch

UTI

Pimples on the thighs

None of these

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Menstrual History. Are/were you prone to:* This field is required.Please check all that apply

Cramps/pain

Heaviness of flow

Irregular cycles

Mood changes

I no longer menstruate and I've check the boxes of what used to apply

I no longer menstraute and none of these apply to me

None of these apply

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Do you have any hormonal issues? Please describe.* This field is required.

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GUT MICROBIOMEThis section will collect information regarding your digestion and gut microbiome

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Which of these do you commonly experience?* This field is required.Please check all that apply

"Goat pellets" small dry pebble-like bowel movements

Loose/soft/pasty stools

Watery stools (possibly with undigested food)

Burning stools with a strong odor

Incomplete feeling after bowel movement

"Comet stools" firm dry stool initially and then soft paste right afterwards

Having to inhale and bear down to pass stools

Well formed, easy to pass stool

Other

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How often do you have a bowel movement on average?* This field is required.

Daily

Multiple times per day

Every other day

1-2 times per week

Less than once a week

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SKIN MICROBIOMEThis section will explore the health of your skin microbiome

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COGNITIONThis section will explore your cognitive processes

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TONGUEPlease take a photo of your tongue like this example. Make sure it is relaxed, and the lighting is good.

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Please upload the photo you just took right hereIf you are having trouble uploading, skip this step and email the image as an attachment to support@modern-vitality.com

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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TONGUEPlease take a photo of the underside of your tongue like this example. Make sure the lighting is good.

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Please upload the photo you just took right hereIf you are having trouble uploading, skip this step and email the image as an attachment to support@modern-vitality.com

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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PLEASE TAKE A SELFIEWith a neutral expression, good lighting, just like the example here

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Please upload the photo you just took right hereIf you are having trouble uploading, skip this step and email the image as an attachment to support@modern-vitality.com

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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MINDSETThis section will explore your your psychology, resilience, and worldview

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What principles do you live by?* This field is required.If you haven't thought about this before, take a minute and consider your values and how you show up to yourself and to the world

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What is the nicest thing you've ever done for someone else without expecting anything else in return?* This field is required.

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Do you have any bad habits? What are they?* This field is required.

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In terms of your health goals, what have you tried so far? Please be specific.* This field is required.For example, health care practitioners, a health program or group, etc.

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How do you feel that the Modern Vitality approach is different from the things you've tried in the past?* This field is required.

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What specifically would you like us to help you with?* This field is required.

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If we were sitting down talking a year from now, what would have needed to happen in that time for you to feel successful with your health?* This field is required.

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What would be different about your life in that case?* This field is required.

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What do you feel are the biggest obstacles to getting better? Why can't you do it by yourself?* This field is required.

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What are the top 3 things you're currently missing out on in life due to symptoms?* This field is required.You should know this from the members vault Shrinking World exercise

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What did you calculate your 5 year "cost of staying sick" to be? (Including lost income)* This field is required.You should know this from the members vault Shrinking World exercise

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Have you discovered any secondary gains that may work against your healing?* This field is required.You should know this from the members vault Cost of getting better

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How do you feel about these secondary gains? How do you plan to confront them?* This field is required.

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Why do you want to get better? Why not just stay where you are with your health as it is?* This field is required.

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How are you currently structuring your self care?* This field is required.

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What is your current plan to work towards medical independence?* This field is required.

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If your application is successful, how soon would you like to begin?* This field is required.

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Which annual membership level are you applying for? Please note that MVSE membership includes the Signature Program

MV Signature Program (MVSP) $7,500 USD

MV Signature Experience (MVSE) $12,500 USD

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Which annual membership level is the best fit for you?* This field is required.

MVSE Live Retreats (includes 12 Month MVSP): $15,000 USD

MVSP Annual (12 Month) Membership: $7,500 USD

MVSP Quarterly (3 Month) Membership: $2,400 USD

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Important: The price for the MVSP is currently $7,500 USD (Annual Membership) or $2,400 USD (Quarterly 3-month Membership). If your application is successful will you be able to make this investment in yourself?* This field is required.

Yes!

Hell Yes!

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Would you like to be considered and invited when we resume having our MVSE Live Retreat Events?* This field is required.

Absolutely

No thank you

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Do you have any questions or concerns?* This field is required.(Payment, terms, and conditions are dependent upon acceptance of this application, and if approved that will be our next step together)

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Is there anything else that makes your case unique? Why should we choose to work with you?* This field is required.

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I have completed this application in full and it's ready to submit to Jeremy for consideration.* This field is required.Click and drag to sign below

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