Color Pattern Assessment Form

Color Pattern Assessment Form
Full Name

First NameLast Name
Email Address
example@example.com
Age
Primary Concerns
Skin and Eye Patterns (Select all that apply)

Dry skinBumpy or rough skinPoor night visionCracked or peeling lipsRed or itchy eyesRough or scaly rashFine lines or premature wrinklesEasy bruisingRed dot skin (petechiae)Inflamed or irritated skinEczemaBleeding gumsNone of these
Nerve and Mood Patterns (Select all that apply)

Tingling or numbnessMuscle weaknessAnxietyDepressionRestlessnessPMS mood swingsCracked lipsMemory issuesBrain fogNerve painFatigue + irritabilityNone of these
Energy and Adrenal Patterns (Select all that apply)

FatiguePoor stress responseHeadachesFeeling “wired but tired”Dark circlesLow blood pressureDifficulty waking upIrritability under stressNone of these
Blood Sugar Patterns (Select all that apply)

Sugar cravingsFatigue after eatingFeeling shaky if you skip mealsIrritability before eatingUnstable energy levelsDifficulty losing weightNone of these
Thyroid and Metabolism Patterns (Select all that apply)

Cold sensitivityWeight gain or slow metabolismNeck swelling or fullnessBrittle nailsHair thinningHeavy fatigueDry skinNone of these
Hair and Nail Patterns (Select all that apply)

Hair loss or thinningBrittle nailsSlow wound healingPale skinChronic fatigueNone of these
Hydration and Electrolyte Patterns (Select all that apply)

ConstipationMuscle crampsTwitchingBloatingDizzinessIrregular heartbeatBrain fogWeaknessInsomniaNone of these
Digestion and Appetite Patterns (Select all that apply)

Low appetiteNauseaBloating after mealsConstipationLoose stoolsHeartburnFood sensitivitiesNone of these
Water intake per day

Under 30 oz30–60 oz60–90 ozOver 90 oz
Stress level most days

LowModerateHighOverwhelmed
Sleep quality (describe briefly)
Final Notes: Share anything else you feel is relevant ( stress, cycle, diet, supplements, etc.)
Should be Empty: