Clone of 1 Hour Macro Consultation Questionnaire w/payment

Comprehensive Energy & Metabolism Audit

Welcome! This assessment helps me understand what's happening in YOUR body so I can give you personalized, root-cause insights. It takes about 10-15 minutes to complete. Answer as honestly as you can—there are no "wrong" answers.
Personal Information
Name*
Email address*
Age*
Are you currently on HRT or BHRT? (Y/N)*
Current medications or supplements (list all, or write 'none')*
Perimenopause / Menopause / Postmenopause (choose one)*
What are your TOP THREE symptoms right now?*
Nervous System Stress Load

Rate each 0–5 (0 = never, 5 = daily)
I wake up already tired or tense.*
I feel overwhelmed more easily than I used to.*
Small things trigger irritability or frustration.*
I experience afternoon energy crashes.*
I get “tired but wired” at night.*
It takes me a long time to wind down before bed.*
I rely on caffeine to get through the day.*
I often feel on edge, overstimulated, or “fried.”*
My heart rate feels elevated even at rest.*
Hidden stress questions:
Do you feel responsible for everything/everyone?*

YesNo
Are you constantly multitasking?*

YesNo
Do you struggle to rest without feeling guilty?*

YesNo
Metabolic Stress & Blood Sugar Patterns

Rate each 0–5 (0 = never, 5 = daily)
My weight increases even when I eat “clean.”*
I skip meals or under-eat without meaning to.*
I feel shaky, hangry, or irritable when hungry.*
I get energy spikes followed by crashes.*
I rely on carbs, caffeine, or snacking for energy.*
I crash after meals or feel heavy/tired.*
My cravings increase when stressed or tired.*
I feel full for less than 2 hours after a meal.*
Are you intentionally restricting calories?*
Do you track protein? If yes, how much do you eat per day?*
Hormone Symptom Patterns
Estrogen under stress (check all that apply):*

BloatingMood SwingsHeavy/unpredictable bleedingBreast tendernessMid-cycle anxiety
Progesterone under stress: (check all that apply):*

IrritabilityAnxietySleep problemsSpottingShort cycles
Cortisol under stress (check all that apply):*

Morning DreadBelly FatBrain FodCravingsAfternoon CrashFeeling WiredFeeling “flat” or unmotivated
Thyroid under stress (check all that apply):*

Weight gainCold hands/feetConstipationDry skin/hairLow energySlow metabolism
Sleep Quality

Rate each 0–5 (0 = never, 5 = often)
I fall asleep easily.*
I stay asleep through the night.*
I wake up feeling rested.*
I wake up during the night hot or anxious.*
I wake up around 2–4 AM.*
I need naps to get through the day.*
Hidden Stressors Checklist
Check all that apply.*

Blood sugar instabilityPoor sleepNutrient deficienciesDigestive issues (bloat, gas, constipation, loose stools)Chronic inflammation (aches, puffiness)Over-exercisingHigh emotional loadOver-responsibilityHigh work stressEnvironmental toxin exposureAlways rushingSensory overload
Life Load & Capacity
On a scale from 1–10, how overwhelmed do you feel most days?*
How much energy do you realistically have for change right now?*
What does a typical day look like?*
What is your biggest challenge in staying consistent?*
What is one thing you wish you understood about your body?*
Your Personal Goals
What do you most want to improve right now?*
What would “feeling like yourself again” look like?*
If I could help you fix ONE thing first, what would it be?*
Lifestyle Analysis
Daily rhythm & movement
How many hours do you typically sit each day?*
How often do you walk or move intentionally (0 = rarely, 5 = multiple times daily)?*
How often do you exercise to exhaustion? (0 = never, 5 = daily)*
Nutrition & hydration habits
How many meals do you eat each day?*
Do you eat breakfast within 1 hour of waking?*
How much water do you drink daily?*
How often do you rely on caffeine or snacks for energy? (0 = never, 5 = daily)*
Sleep & recovery rhythm
Average bedtime / wake time*
How consistent are your sleep hours (0 = chaotic, 5 = consistent)?*
How often do you feel rested in the morning? (0 = never, 5 = always)*
Environment & self-care
Screen time after 8 pm (Y/N)*
Average daily outdoor or sunlight exposure (minutes)*
How often do you feel rushed all day? (0 = never, 5 = always)*
Let's Go!
What do you hope to leave this consultation with?*
Is there anything else you would like me to know? What specific questions do you have for me?*

My Products

Energy & Metabolism Audit

Within 3-5 business days after this form is submitted, you will receive an email with your report and a link to schedule your 30-minute call to go over your results.

$397.00 Quantity

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Comprehensive Energy & Metabolism Audit

Personal Information

Nervous System Stress Load

Hidden stress questions:

Metabolic Stress & Blood Sugar Patterns

Hormone Symptom Patterns

Sleep Quality

Hidden Stressors Checklist

Life Load & Capacity

Your Personal Goals

Lifestyle Analysis

Daily rhythm & movement

Nutrition & hydration habits

Sleep & recovery rhythm

Environment & self-care

Let's Go!