Wellbeing Self Assessment

Discover What Your Body Really Needs
Welcome!

Before you begin, take a slow breath in… and let it go.

This reflection is an invitation to pause and listen — not to judge or fix. Your body has been communicating with you for a long time, and this is a moment to tune in with honesty and care.

There are no right or wrong answers here. Just respond thoughtfully, based on what feels true right now.

This is an important step in your health — not because you need more information, but because clarity creates momentum.

Your responses allow me to:
- Understand what’s really going on beneath the symptoms
- Identify metabolic, hormonal, gut, inflammation & nervous system patterns
- Offer personalized insight and next-step guidance
- Determine whether a 1:1 conversation feels aligned
Thank you for being here and taking this step for yourself.

*All information is confidential and used only to guide your wellness journey.
Full Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
E-mail
example@example.com
Under 3535-3939-4545-4950-5555-59over 60
I'm not sure - I feel pretty good.I'm not sure - I just don't feel like myself.I know I'm experiencing PerimenopauseI am in Menopause (I have not had a period in 12 months or more)I'm in a season of high stress possibly even burn out.I am recovering from dieting, GLP-1s or calorie restriction.I'm going through a major life transition. (career, relationships, children, moving)Something else not listed.
Low energy or fatigue especially after mealsDifficulty sleeping or poor-quality sleepBrain fog or trouble concentratingMood swings or low moodDigestive issues (bloating, gas, sluggish or constipation)Weight Gain despite healthy habitsSkin concerns (aging, dullness, dryness, new breakouts)Joint pain, stiffness, or inflammationBlood sugar dips or sugar cravingsLoss of muscle tone or strengthAnxietyDry, brittle or thinning hair
I want balance - not extremesI understand my metabolismI feel confused by conflicting adviceI've tried everything and feel frustratedWeight is not a focus
Menstrual CycleHot flashes or night sweatsMood or anxietyLibidoPMS symptomsHair thinningSkin changes
Hormone Replacement Therapy (HRT)Birth ControlSupplements for hormone supportNothing Currently
BloatingConstipation or DiarrheaFood SensitivitiesJoint pain or stiffnessHeadachesSkin inflammation (redness, scaling, itchy...)Frequent illness or low immunity
Smooth and consistentsome challenges - but manageableOngoing struggle
What feels like the biggest challenge in your health right now? (List everything you can think of)
CoffeeTeaEnergy DrinksOther
Please list any current medications or supplements you’re taking so I can ensure your recommendations are safe and supportive for your body. ie. Weight Loss Medication, Omega3, Collagen, Daily Vitamins, Amino Acids, Creatine, Electrolytes, Protein Supplement, Sleep Aids, Pain Meds, Zinc, Ecinachea, Turmeric, CoQ10*
Has your healthcare provider mentioned anything you should avoid or limit when it comes to supplements or nutrition?
What have you already tried that hasn’t worked? (List everything you can think of)
More EnergyHormonal BalanceReduced InflammationMore Mental ClarityI would like to lose weight and improve my metabolismI would love to feel like myself again.I would like to know what supplements or modalities might help meI would like simple healthy meal prep ideasI would like to hear from other women experiencing the same things.
I'm exploring and learningI'm ready for guidanceI want personalized supportI'm open but cautiousI feel overwhelmed and unsure
YesPossiblyNot at this time
I understand and agree
Should be Empty:

Discover What Your Body Really Needs