Synthesis Health Signature Program Application

1

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.

2

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

3

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

First Name

Last Name

4

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

example@example.com

5

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

Male

Female

6

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

7

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

Yes

8

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

9

What is your height?* This field is required.

10

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

12

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

YESNO

13

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

14

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

15

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

16

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

17

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)

18

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

19

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

20

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

21

Can you fill in the blank? "I've never felt the same ever since ____________________"* This field is required.

23

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

25

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

Mold Exposure

Chemical Exposure

Tick Bites

Parasites

None of these

26

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

27

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

28

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

29

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

30

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

31

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

32

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

YESNO

33

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

34

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

YESNO

35

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

36

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

37

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

38

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

39

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

41

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

42

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

43

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

YESNO

44

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

45

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

Lose Weight

Gain Weight

Neither

47

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

48

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...

49

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

50

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

51

SLEEP + RECOVERYThis section will evaluate the quality of your sleep

53

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

54

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

55

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

56

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

57

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

58

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

59

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

60

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

61

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

62

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

63

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

64

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

65

SKIN MICROBIOMEThis section will explore the health of your skin microbiome

67

COGNITIONThis section will explore your cognitive processes

72

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

73

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@synthesishealth.co.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

74

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

75

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@synthesishealth.co.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

76

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

77

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@synthesishealth.co.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

78

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

79

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

80

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

81

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

82

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.

83

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

84

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

85

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.

86

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

87

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

88

What are the top 3 things you're currently missing out on in life due to symptoms?* This field is required.

89

What is your 5 year "cost of staying sick"? (Including medical expenses + lost income)* This field is required.

90

Have you discovered any secondary gains that may work against your healing?* This field is required.Any unconscious benefits of staying in your current situation

91

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

92

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

93

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

94

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

95

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

96

Which annual membership level are you applying for? Please note that SHSE membership includes the Signature Program* This field is required.

SH Signature Program (SHSP) $7,500 USD

SH Signature Experience (SHSE) $12,500 USD

97

Important: The price for the 12 Month Membership in the SHSP is currently $7,500 USD, and the SHSE is $12,500 USD. If your application is successful will you be able to make this investment in yourself?* This field is required.

Yes!

Hell Yes!

98

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)

99

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

100

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

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