GUT QUIZ

Gut Health Quiz

Kindly fill out the form provided below and one of our friendly representatives from Wholistic Essentials will be in touch with you shortly. Please note this is not intended to diagnose or treat pathological conditions, illnesses, injuries, or disease.
Please note, we work exclusively with clients in North America “United States and Canada” who are 18 years or older.
Full Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
What is your gender?*

MaleFemale
Check the conditions that apply to you*

AsthmaCancerDiabetesHypertensionIrritable Bowel SyndromeReactive ArthritisEczemaDiarrheaGastroenteritisAcid RefluxSmall intestinal bacterial overgrowth (SIBO)Inflammatory Bowel DiseaseFibromyalgiaMigraineChronic UrticariaRheumatoid ArthritisChronic Fatigue SyndromeADD/ADHDCeliac DiseasePainful MensesHalitosis(Bad Breath)Other
Check the symptoms that you're currently experiencing:*

Weight gainWeight lossBloatingIrregular bowel movementsAbdominal painRashBreakoutsHeadachesJoint painFatigueMoodinessOther
How long have you been experiencing these challenges?*

3 months or less6 monthsLess than 1 yearLonger than a year
Do you have any allergies?*

YesNoNot Sure
What steps have you currently taken to help resolve your health concerns? Have you noticed any changes from this approach?*
Have you ever taken a gut test?*

YesNo
Have you ever taken a food sensitivities test?*

YesNo
If yes… what did these test results find?
How often do you prepare healthy meals that include vegetables, fruits, grains and legumes?*

Daily2-3X Week3-5X WeekNever
How often do you exercise?*

Daily2-3X Week3-5X WeekNever
What are you looking to achieve?*
Are you interesting in learning more about my 1-on-1 gut health nutrition services?*

Yes, please have someone reach out to me ASAP!Not ready yet, please send me more information.
What is the best way to reach you?*

PhoneEmail
How did you learn about us?*

Tik tokFacebookInstagramReferral
Where are you located?*

United StatesCanadaOther
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Gut Health Quiz