End of GutStrong
Personal Health Assessment [PHA]
Instructions...
At the end of the first page (section) click the
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ENSURE
you click the
SAVE
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if you are still continuing
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Today's Date
-
Day
-
Month
Year
Date
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
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HEALTH, MEDICATIONS AND SUPPLEMENTS
Using ONE line per issue... List ALL any health issues(even little niggles) you are CURRENTLY experiencing
*
Using ONE line per each medication... List all prescribed medications (including contraceptives) AND any over-the-counter drugs (e.g. Nurofen, Panadol etc.) you are currently taking (not supplements) If NONE, please type in NONE
*
Using ONE line per each Supplement... List all supplements that you take (even if sporadic) If NONE, please type in NONE
*
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SLEEP
How many hours of sleep do you get (on average)
*
Please Select
Less than 5 hours
5-6 hours
7-8 hours
8 hours or more
Your average 'hours' of sleep
Ease of Falling Asleep... rating
*
Please Select
0 =Terrible (greater than 40-mins to sleep)
1 = Poor (30-40 mins to sleep)
2 = Fair (20-mins to sleep)
3 = Good (10-mins to sleep)
4 = Very Good (Less than 10-mins to sleep)
5 = Excellent (Fall asleep immediately)
Refers to the time it takes to fall asleep once you put your head on the pillow
Awakenings...
*
Please Select
More than 10x a night
10x a night
8x a night
5 x a night
2-3x a night
5 = Excellent (1-2x a night)
Refers to the number of times you WAKE UP during 'sleep hours'
Ease of Falling back to sleep after waking... rating.
*
Please Select
0 =Terrible (after waking, takes more than 30-mins to get back to sleep)
1 = Poor (takes 20-mins to get back to sleep)
2 = Fair (takes 10-mins to get back to sleep)
3 = Good (takes 5-mins to get back to sleep)
4 = Very Good (Less than 5-mins to get back to sleep)
5 = Excellent (Fall back asleep immediately)
Refers to how easily you fall back to sleep after waking
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MOOD, STRESS & CONCENTRATION…
Can be connected with work, home life, social situations, family, friends, relationships, finances, health concerns, world issues.
Anxiety... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Anxiety... select ALL that apply
*
Restlessness
Tension
Nervousness
Intrusive thoughts or concerns
Feeling of unease
Feelings of dread
Feel like heart is racing or pounding
Excessive sweating when stressed
Trembling or shaking
Shortness of Breath:
Feeling on edge
Easily frustrated or agitated.
Overwhelming sense of dread
Panic attacks
None of the above
Overwhelm... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Overwhelm... select ALL that apply
*
Flooded with thoughts
Disproportionate reactions
Feeling helpless and hopeless
Feeling paralysed
Crying easily
Cognitive fatigue
Increased apathy
Fluctuating emotions
None of the above
Frustration... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Frustration... select ALL that apply
*
Anger or losing temper quickly
Avoidance
Annoyed and irritable
On edge
Giving up on tasks
Flitting from one task to another
Incessant body movement
Using food or substances to cope
None of the above
Mind is ALWAYS on... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
This can relate to something; typically, a problem or situation, or a person or circumstance.
Mind is ALWAYS on... select ALL that apply
*
Racing Thoughts
Inability to focus or concentrate
Overthinking or overanalysing
Difficulty switching off
Constant planning or worrying
Difficulty being present
Procrastination/Avoidance
Constant engagement in stimulating activities
None of the above
Sad and/or lonely... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Signs can differ from person to person. However, these are some of the common signs...
Sad and/or lonely... select ALL that apply
*
Feeling down, empty or hopeless
Loss of interest or enjoyment
Overwhelming sense of isolation
Feeling disconnected from others
Longing for social interaction
Feeling unable to connect
Withdrawal from social situations
Withdrawal from friends or family
Avoiding contact with others
Excessive time alone
Negative thoughts
Ruminating over mistakes
Ruminating over missed opportunities
Feelings of regret
None of the above
Poor or Low concentration... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Concentration... select ALL that apply
*
"Drained" or unable to think clearly
Difficulty focusing
Forgetfulness
Difficulty organizing thoughts
Feel like mind is working in slow motion
Feeling of disorientation
Difficulty finding words
Poor memory recall
Easily distracted
Jump back and forth between tasks
None of the above
Experience Stress... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Signs of stress are far reaching... include physical changes to the body, skin and health, as well as emotional, mental, cognitive and behavioural changes that EITHER rev you up OR shut you down
Stress... select ALL that apply
*
Muscle tension or jaw clenching
Substance use or abuse
Racing thoughts
Craving sweet foods
Change in appetite
Fidgeting, inability to relax
Intake of salty snacks
Increased use of alcohol
Feeling helpless
Increased use of caffeine
Reduced productivity
Feeling out of control
Feeling detached
Unexplained weight change
Feeling numb or emotionally flat
Feeling like you can't stop being busy
Overreacting to small inconveniences
Excessive scrolling social media
Increased clumsiness
Nail biting or picking at skin
Avoiding people without clear reason
Keep busy to avoid stopping
Reacting to how drivers on the road act
Reacting to how others act
Excessive cleaning/organising
Difficulty in prioritizing health over life
Quick to temper
Excessive streaming/TV watching
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DIGESTION…
Heartburn... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Signs are… Burning sensation in the chest or throat, often felt after eating or lying down. Regurgitation: A sour or bitter-tasting acid that backs up into your throat or mouth, especially when bending over or lying down. Difficulty swallowing (dysphagia): A feeling of food being stuck in your chest or throat.
Reflux... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Signs are… Regurgitation: Feeling of food and acid coming up into the throat. Chest pain: Such as sharp or dull chest discomfort, especially after eating. Bloating: A feeling of fullness or pressure in the abdomen. Nausea or upset stomach: Especially after eating. Worsening symptoms when lying down or after eating: Tends to worsen when lying flat or after a large or spicy meal.
Belching or Burping... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Signs are… Release of air from the mouth, either loud or soft can be accompanied by a feeling of fullness or pressure in the upper abdomen.
Bloating... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Signs are… When your abdomen feels swollen or distended, or a feeling of tightness. Your stomach may appear larger than usual, and your clothes may feel tighter around your waist.
Flatulence (gas)... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Signs are… a release of gas from the digestive system through the rectum.
Abdominal pain, cramps or spasms... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Signs are… A dull or sharp ache, cramping, or tenderness in the stomach area. You may feel a build-up of pressure in the abdomen, leading to increased gas expulsion.
Cravings... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Signs are… An intense desire or urge to eat specific types of food, often outside of regular hunger cues. It is a strong desire for a particular food or taste i.e. sweet or salty snacks.
Bowel movements... frequency
*
Please Select
Once a day
Twice a day
Three times a day
4 times, or more, a day
1 -2 times, every second day
1 -2 times, every third day
1 -2 times, every fourth day
Once a week
How many bowel movements a day
Bowel movements... Describe timing, speed, colour, odour
*
Please refer to the time(s) of day you pass a bowel movement. Speed… How long does it take to pass? Colour… Black, Brown, Red, Greenish, Orange'ish, Yellow’ish, Pale grey? Consistency… Separate hard lumps like nuts? Sausage shaped but lumpy? Sausage like cracked surface? Smooth Sausage like? Soft blobs with clear cut edges? Fluffy with ragged edges/mushy? Watery, no solid pieces? Sticky/Greasy? Odour… None? Bad odour? Or smells like?
One line per food... List the foods you are sensitive/Intolerant to
*
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ENERGY…
Energy on waking... rating
*
Please Select
0 = Terrible (extremely low energy)
1 = Poor (very low energy)
2 = Fair (not that good, not that bad)
3 = Good (good energy)
4 = Very Good (high energy)
5 = Excellent (outstanding energy)
Energy - throughout the day... rating
*
Please Select
0 = Terrible (extremely low energy)
1 = Poor (very low energy)
2 = Fair (not that good, not that bad)
3 = Good (good energy)
4 = Very Good (high energy)
5 = Excellent (outstanding energy)
Energy - from evening to bedtime... rating
*
Please Select
0 = Terrible (extremely low energy)
1 = Poor (very low energy)
2 = Fair (not that good, not that bad)
3 = Good (good energy)
4 = Very Good (high energy)
5 = Excellent (outstanding energy)
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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.. rating
*
Please Select
0 = Terrible (extremely bad )
1 = Poor (very low)
2 = Fair (not that good, not that bad)
3 = Good (good complexion)
4 = Very Good (very good complexion)
5 = Excellent (Outstanding complexion)
Refers to the texture and appearance of the skin on your face... around eyes, eyebrows, forehead, nose, cheeks, lips and chin.
Face condition... select ALL that apply
Lumps
Bumps
Large pores
Flaky and/or dry
Oily
Oily T-zone
Redness
Discolouration
Pigmentation spots
Sunspots
Acne
Blind pimples
Pimples
Whiteheads
Blackheads
Rosacea
Fine lines
Excessive wrinkling
Psoriasis
Eczema/Dermatitis/Rash
None of the above
Body condition.. rating
*
Please Select
0 = Terrible (extremely bad )
1 = Poor (very low)
2 = Fair (not that good, not that bad)
3 = Good (good condition)
4 = Very Good (very good condition)
5 = Excellent (Outstanding condition)
Refers to the texture and appearance of the skin over your body... inspect your neck, arms, hands, fingers, torso (including genitals), legs, feet and toes then please .
Body condition... select ALL that apply
Lumps or bumps
Dry or scaly
Blisters or sores
Oily
Redness
Red itchy patches
Yellowing of skin
Dark spots
Sunspots
Acne, on back
Pimples or bumps on arms
Psoriasis
Eczema/Dermatitis/Rash
Warts
Swelling (edema)
Unusual hair growth
Crusting or Weeping Skin
Itchiness (Pruritus)
Pain or Tenderness
Loss of Firmness
None of the above
Hair and Scalp condition.. rating
*
Please Select
0 = Terrible (extremely bad )
1 = Poor (very low)
2 = Fair (not that good, not that bad)
3 = Good (good condition)
4 = Very Good (very good condition)
5 = Excellent (Outstanding condition)
Refers to the texture and appearance of the hair and scalp. We recommend getting help to inspect your scalp.
Hair and Scalp condition... select ALL that apply
Dry hair
Normal hair
Oily/Greasy hair
Frizzy hair
Damaged hair
Hair loss
Bald patches
Dandruff
Flaky skin on scalp
Psoriasis on scalp
Eczema/Dermatitis/Rashes on scalp
Itchiness (Pruritus) on scalp
None of the above
Fingernails condition.. rating
*
Please Select
0 = Terrible (extremely bad )
1 = Poor (very low)
2 = Fair (not that good, not that bad)
3 = Good (good condition)
4 = Very Good (very good condition)
5 = Excellent (Outstanding condition)
Refers to the texture and appearance of the fingernails
Fingernails condition ... select ALL that apply
*
Ridges, ripples or lines
Pitted/grooves
Cracked or split
Discolouration
White spots
Thin, flaky, peeling
Thick and strong
Easily break
Dry or handing cuticles
Fungus
I bite my nails
I pick at my nails
Clubbing (rounded or bulging nails)
None of the above
Toenails condition.. rating
*
Please Select
0 = Terrible (extremely bad )
1 = Poor (very low)
2 = Fair (not that good, not that bad)
3 = Good (good condition)
4 = Very Good (very good condition)
5 = Excellent (Outstanding condition)
Refers to the texture and appearance of the toenails
Toenails condition ... select ALL that apply
*
Ridges, ripples or lines
Pitted/grooves
Cracked or split
Discolouration
White spots
Thin, flaky, peeling
Thick and strong
Easily break
Dry or hanging cuticles
Fungus
None of the above
Tongue condition ... select ALL that apply
*
Bright red or beefy appearance
Clear and shiny
Cracked/mapped appearance
Greenish-brown colour
Creamy white colour
Yellowish colour
Clay coloured
Red, sore, inflamed
Groove down the middle
Quivering
Scalloped edges
Strawberry spots
Slimy
Pink, healthy
Lips, mouth and teeth ... select ALL that apply
*
Bad breath
Bleeding gums
Burning mouth
Cold sores
Cracked or broken teeth
Cracked or dry lips
Cracks at sides of mouth
Crown(s)
Dry mouth
Fillings – Ceramic
Fillings – Mercury
Gingivitis
Inflamed or sore gums
Mouth ulcers
Receding gums
Root canals
Sensitivity to hot or cold
Tooth decay
None of the above
Heels of feet... select ALL that apply
*
Smooth, soft and supple
Dry and rough to touch
Flaky skin
Shallow cracks in skin
Thick and callused
Deep cracks in skin
Pain or discomfort when walking
Bleeding, redness or swelling
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RESPIRATORY AND CIRCULATION...
Asthma and/or Wheezing.. rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Hay fever .. rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Dark circles under eyes .. rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Bags or puffiness under eyes .. rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Phlegm in throat and/or postnasal drip .. rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Refers to sensation of mucus dripping down the back of the throat from the nasal passages. Constant throat clearing, coughing (esp. at night), sore or scratchy throat, discomfort when swallowing, excessive swallowing to clear your throat. If NEVER, please write "never
Swollen legs, ankles and/or feet .. rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Swollen arms, wrists and/or hands... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
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ACHES AND PAINS...
Headaches and/or Migraines.. rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
A headache is a pain or discomfort in the head, scalp, or neck. Where as a migraine typically cause moderate to severe throbbing pain, often on one side of the head. Can last from hours to days. May be accompanied by nausea, vomiting, and sensitivity to light or sound.
Body aches, pains or spasms... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Refers to any type of ache, pain or spasm anywhere in the body
Briefly state where the aches, pains and spasms are...
Restless leg syndrome [RLS]... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Refers to an irresistible urge to move the legs, often accompanied by uncomfortable sensations, particularly in the evening or at night, making it difficult to fall or stay asleep. The condition can be mild or severe and sensations experienced can be a feeling of crawling, tingling, throbbing, pulling sensation, pins or needles or itching feeling in the legs. The urge to move the legs usually occurs during periods of rest or inactivity, particularly when sitting or lying down.
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HORMONES, URINARY...
Peri-menopause / Menopause symptoms
*
Brain fog
Fatigue
Headaches
Hot flashes
Irregular periods
Migraines
Mood changes
Night sweats
Poor concentration
Sleep disturbances
Vaginal dryness
Weight gain
None of the above
Daytime Hot flushes... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Refers any or all of the following... Intense sudden hot flush with sweating, slow increase in heat with no sweating, heat followed by a chill, red blotches, heart palpitations
Night-time Hot flushes... rating
*
Please Select
0 = Always (100% of the time)
1 = Often (90% of the time)
2 = Usually (70% of the time)
3 = Sometimes (50% of the time)
4 = Hardly ever (10% of the time)
5 = Never (0%)
Refers any or all of the following... Intense sudden hot flush with sweating, slow increase in heat with no sweating, heat followed by a chill, red blotches, heart palpitations
Urinary frequency... How many times a DAY do you urinate?
*
Please Select
Once a day
2-4 times a day
5-7 times a day
10 or more times a day
Urinary frequency... How many times a NIGHT do you urinate?
*
Please Select
Once
2 times
3 times
4 times or more
Urine colour...
*
Please Select
Clear
Cloudy
Pale straw
Light Yellow
Gold / Orange
Pink/Red
Brown
What is the most common colour
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Measurements
Now it's time to compare your START measurements to your END measurements
Height (in centimetres)… Please have someone measure for you, do NOT estimate
*
Just enter the number NOT the word "cm"
Weight (in kilograms)… Take a note at what time of day, with or without clothes, that you weighed yourself. Do NOT weigh yourself during the program!!
*
Just enter the number NOT the word "kg"
Chest (in centimetres)… Measure around the largest part of your chest (breasts) with the tape across nipples.
*
Just enter the number NOT the word "cm"
Waist (in centimetres)… Measure at the narrowest part of your waist.
*
Just enter the number NOT the word "cm"
Please calculate your Waist-to-height ratio [WHtR] by dividing your waist circumference by your height e.g. 80(cm) Waist ➗161(cm) height = 0.49 (enter this number)
*
From the WHtR above, select category
*
Please Select
≤ 0.34 (Extremely slim)
0.35 – 0.41 (Slim)
0.42 – 0.48 (Healthy range)
0.49 – 0.53 (Overweight)
0.54 – 0.57 (Very overweight)
≥ 0.58 (Obese)
Waist to Height Ratio [WHtR] is a tool for predicting cardiovascular, diabetes and stroke risk, hypertension, and dyslipidemia because it accounts for the distribution of abdominal fat, which is known to increase the aforementioned risks. The WHtR is a measure of fat distribution. A superior tool to detect cardiometabolic risk factors.
Hips (in centimetres)… Measure around the largest part of your buttocks with your heels together.
*
Just enter the number NOT the word "cm"
Right thigh (in centimetres) … Stand with your legs slightly apart, measure where the circumference is largest
*
Just enter the number NOT the word "cm"
Left thigh (in centimetres) … Stand with your legs slightly apart, measure where the circumference is largest
*
Just enter the number NOT the word "cm"
Right bicep (in centimetres) … Measure midway between the top of your shoulder and elbow
*
Just enter the number NOT the word "cm". Note: you're not measuring your left bicep.
Calculate your Body mass index [BMI] by entering your weight in kilograms and height in centimetres below
From the BMI rating above select category
*
Please Select
< 18.5 (Underweight)
18.5 – 24.9 (Healthy range)
25 – 29.9 (Overweight)
30 – 34.9 (Obese, class 1)
35 – 39.9 (Obese, class 2)
40+ (Obese, class 3)
Body Mass Index [BMI] is just one of the many tools used to measure ‘size’, relating to body fat, not dependent on your frame. Correlated with total body fat, it does not distinguish fat from muscle or different body fat distributions.
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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
Full standing photos (side on view) — fully clothed or in bra/underwear, whichever you’re most comfortable with.
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Full standing photos (front on view) — fully clothed or in bra/underwear, whichever you’re most comfortable with.
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Write about HOW you FEEL now compared to when you started GutStrong...
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