Hi, I'm Mandy!

1

What are your top 3 health goals for the next 6 months?

2

How much water do you typically drink each day?

3

How many steps do you usually take per day?

4

What other forms of exercise, if any, do you engage in regularly?

5

Are you aware of how much protein you consume on a daily basis?

YESNO

6

Would you like help tracking or adjusting your protein intake?

YESNO

7

How many hours of sleep do you get each night?

Less than 5

5-7

8-10

More than 10

8

Do you feel rested when you wake up, or do you often feel fatigued during the day?

Yes

No

Sometimes

9

Do you have any sleep issues, such as difficulty falling asleep, staying asleep, or waking up too early?

Yes

No

Sometimes

10

On a scale of 1 to 5, how would you rate your stress levels?1 being not stressed at all, 5 being very stressed.

11

How do you typically manage your stress?

12

Do you feel your stress impacts your sleep or overall health?

Yes

No

Not sure

13

On a scale of 1 to 5, how does your gut feel on a daily basis?1 being extremely uncomfortable, 5 being excellent

14

Do you experience any of the following digestive issues? Such as bloating, constipation, diarrhea, or discomfort?

Bloating

Constipation

Diarrhea

General discomfort

All of the above

15

Do you eat foods that support gut health, such as fermented foods, fibre or probiotics? Please specify below

16

What does a day of your typical diet look like?

17

Are there any food preferences or restrictions I should know about?

18

Do you currently take any supplements or medications?

YESNO

19

If you do currently take any supplements or medications, what are they and what is their purpose?Please specify below. If none, write N/A

20

How would you rate your overall energy levels throughout the day?1 being zero energy, 5 being feeling super energetic

21

Name

First Name

Last Name

22

Phone Number

Please enter a valid phone number.

23

Email

example@example.com