Gut Health Plan
Thank you for taking the time to complete this form. Your answers will help me understand your current gut and hormonal health so I can create a personalised plan for you. This will ensure you get the best results.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
What is your main concern/goal?
Do you experience bloating? If yes, when does it occur? (e.g., after meals, randomly, specific foods)
How often do you have bowel movements?
Daily
Every other day
Less than 3 times per week
Do you experience any of the following?
Constipation
Diarrhoea
Gas
Acid reflux/Heartburn
Have you noticed any food intolerances or sensitivities? If yes, which foods?
Do you take any medications? If yes which ones.
Do you experience PMS symptoms (e.g., cramps, mood swings, cravings, breakouts)? If yes, how bad and which ones.
Do you have a regular menstrual cycle? If no, when was your last cycle.
Have you experienced any of the following?
Fatigue
Unexplained weight gain or loss
Acne or skin issues
Mood swings/anxiety
Are you on any contraceptive?
YES
NO
I was until recently (less than 3 months ago)
Do you have Endometriosis or PCOS?
Endometriosis
PCOS
Both
No, but I believe I might do
No
How many servings of fibre-rich foods (fruits, vegetables, whole grains) do you eat daily (rough amount)?
How much water do you drink per day (roughly)?
How often do you consume fermented or probiotic foods (natural yogurt, kimchi, sauerkraut, kombucha, kefir)?
Never
Sometimes
Oftern
How do you rate your stress levels?
Low
High
Moderate
Do you take any supplements for gut or hormonal health? If yes, which ones?
Is there anything else you'd like to share about your gut or hormonal health concerns?
What day/s would suit you best for a 15 mins call to go through the plan? Would you prefer morning, lunchtime or evening. Also in what country do you reside?
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