Ancestral Protocol

Ancestral Protocol

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Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number*
Requesting Information Regarding

1. What are your main health goals? (e.g., lose weight, improve digestion, increase energy levels, etc.)*
2. What is your current diet like? (e.g., standard american diet, plant-based, animal-based, low-carb, high-carb, keto etc.)*
3. How often per week, do you eat out at restaurants?*
4. Do you have any food allergies, sensitivities or intolerances? If so, please list them:*
5. How often do you consume alcohol or sugary drinks per week?*
6. Do you suffer from any autoimmune diseases? If so, please list them:*
7. Do you take any supplements or medications? If so, please list them:*
8. What is your monthly food budget? (e.g., $200, $500, $1000, etc.)*
9. Are you able to prepare and cook meals for yourself? *
10. How many meals per day do you typically eat?*
11. What does a typical day of eating look like for you? (Breakfast, lunch, dinner)*
12. Do you experience any digestive issues (e.g., bloating, gas, constipation, diarrhea)?*
13. How frequently do you eat processed or packaged foods?*
14. How many hours of sleep do you typically get each night?*
15. What is your current level of physical activity (e.g., sedentary, moderate, high)?*
16. Are there any foods that you have a hard time giving up?*
17. Are you open to trying new foods and recipes?*
18. How motivated are you to make dietary/lifestyle changes to improve your health?*
19. Are you feeling stressed? If so, how many times a week?*
20. What are your biggest barriers or challenges to improving your health? (Nutrition, excercise, emotional support)?*
Should be Empty: