• End of GutStrong

    Personal Health Assessment [PHA]

  • Instructions...

    1. At the end of the first page (section) click the SAVE button. This will prompt you to create an account (with JotForm) which then emails you a link email link to your saved form. Check junk/spam folder if the link is not in your inbox. Email comes from noreply@jotform.com 

    2. At the end of every page (section) ENSURE you click the SAVE button, then click NEXT if you are still continuing. This way you will never lose any inputted information. Your JotForm email link will take you to the place on the form where you left off. 
  • Today's Date
     - -

  • HEALTH, MEDICATIONS AND SUPPLEMENTS

  • SLEEP

  • MOOD, STRESS & CONCENTRATION…

    Can be connected with work, home life, social situations, family, friends, relationships, finances, health concerns, world issues.
  • Anxiety... select ALL that apply*
  • Overwhelm... select ALL that apply*
  • Frustration... select ALL that apply*
  • Mind is ALWAYS on... select ALL that apply*
  • Sad and/or lonely... select ALL that apply*
  • Concentration... select ALL that apply*
  • Stress... select ALL that apply*

  • DIGESTION…

  • ENERGY…

  • SKIN, HAIR, NAILS, MOUTH…

    We highly recommend taking a photo of any issues, so you have a visual record. This way you can easily compare progress when updating.
  • Face condition... select ALL that apply
  • Body condition... select ALL that apply
  • Hair and Scalp condition... select ALL that apply
  • Fingernails condition ... select ALL that apply*
  • Toenails condition ... select ALL that apply*
  • Tongue condition ... select ALL that apply*
  • Lips, mouth and teeth ... select ALL that apply*
  • Heels of feet... select ALL that apply*

  • RESPIRATORY AND CIRCULATION...

  • ACHES AND PAINS...

  • HORMONES, URINARY...

  • Peri-menopause / Menopause symptoms*

  • Measurements

    Now it's time to compare your START measurements to your END measurements

  • Visual Health Record

    Photos are one of the most powerful tools you can use to track your progress. While numbers on a scale or measurements can tell part of the story, photos often reveal changes you might not notice day to day. They capture posture, shape, skin health, and overall vitality in ways that written notes cannot. These images will remain private and secure. This is OPTIONAL
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