Brynn Elisabeth Health Interest Form

Brynn Elisabeth Health Interest Form
Thanks for your interest in working with me! Fill out this quick form to help me figure out how I can best serve you.

If you haven't already -> schedule a free 30 minute consultation HERE to discuss if we'd be a good fit to work together!
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Age
What state do you live in?
Only ask this because some states may have different rules and fees for lab ordering
What are your main health complaints?
How long has this been going on?
How are your symptoms impacting your life? Why are you finally looking for help now?
Have you worked with another health coach, holistic practitioner, therapist, etc. for your symptoms?

YesNo
If yes, please describe
What have you tried so far for your symptoms that has or has not helped?
Are there any barriers that might get in the way of improving your health? (money, time, environment, fear, limiting beliefs, lack of social support, etc if any?)
What do you reasonably expect to achieve working with me? What are your main goals? What does life look like at the end of this process? Be as detailed as possible!
On a scale of 1-10, how committed are you to improving your health?
My programs will likely require you to make meaningful changes to your lifestyle and daily habits to see results. Success will depend on your commitment.
If we decide it will be helpful, I am willing to ...

Eat a mostly whole food dietEat regular, balanced meals throughout the dayCook meals at homeTrack food/keep a food diaryInvest in high quality foodInvest in supplementsStay consistent with taking supplementsManage stressAdjust my sleep schedule and routinesGet daily movement throughout the dayDo mental/emotional work (journaling, therapy, etc)Set boundaries with work, people, habits that aren't serving youTrack symptoms and progress over timeShow up to sessions on timeTake personal responsibility for my progressBe open-minded and coachableShare wearable data with me if applicable (Oura, Whoop, Garmin, FitBit, etc)
What testing are you most interested in, if any?

GI-MAP stool testingFunctional bloodwork panelDUTCH hormone testingHair Tissue Mineral AnalysisI'm not sure yetOther
Do you have any recent bloodwork or functional test results already (within the past 6 months) that you'd be willing to share?

This can help guide us to where to look next. The more data the better!
Cancelof
What excites you most about working with me?!
Anything else you want to share?
Thank you for your interest!

If you haven't already -> schedule a free 15 minute discovery call with me HERE to discuss if we'd be a good fit to work together!
Should be Empty: