Body Sings System Assessment

Body Sings System Assessment

A system-based intake to triage your current state into the right optimization tier.
Client Baseline
Client Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Age*
Gender*
Height*
Weight*
Primary Concern*
Nervous System & Recovery
1. Difficulty initiating or maintaining sleep (>3 nights/week)?*

0

1

2

3

4

0 is Never, 4 is Persistent/Severe or Diagnosed
2. Brain fog, impaired focus, or memory decline affecting function?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
3. Heightened stress reactivity (anxiety, irritability, overstimulation)?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
4. Headaches, migraines, or tension-related cranial symptoms?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
5. Persistent mental fatigue despite adequate rest?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
6. Sensory sensitivity (light, sound, environmental triggers)?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
7. Mood instability (mood swings, low motivation, emotional dysregulation)?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
Full Body Optimization
8 . Chronic low energy or fatigue with routine activity?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
9. Join pain, stiffness, or muscle soreness impacting mobility?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
10. Digestive dysfunction (bloating, reflux, constipation, irregularity?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
11. Reduced exercise tolerance (difficulty sustaining > 30 min moderate activity?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
12. Frequent illness or delayed recovery (immune relience)?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
13. Signs of suboptimal hydration (dryness, headaches, low output)?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
14. Physical imbalance (weakness, instability, coordination issues?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
Advanced Preventative
15. Diagnosed chronic condition (hypertension, diabetes, autoimmune, etc.)?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
16. Infrequent or absent monitoring of key biomarker (blood pressure, fasting glucose, lipid panel, basic labs, inflammatory markers)?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
17. Strong family history of chronic disease (cardiac, metabolic, cancer, etc.)?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
18. Lack of routine preventative screening (labs, exams, imagine)?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
19. High-risk lifestyle exposure (smoking, alcohol, recreation drugs, sedentary?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
20. Presence of early warning symptoms (unexplained fatigue, weight change)?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
21. Low adherence to structured health optimization practices (nutrition plan, regular exercise, sleep hygiene, stress management, supplementation) ?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
Cardio-Metabolic Optimization
22. Elevated blood pressure or hypertension diagnosis ?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
23. History of cardiac disease (arrhythmias, CAD, surgical intervention) ?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
24. Impaired glucose control (prediabetes, diabetes 1 or 2, insulin resistance) ?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
25. Shortness of breath with mild exertion ?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
26. Chest discomfort, palpitations, or irregular heartbeat ?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
27. Abnormal lipid profile (most recent labs) ?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
28. Central adiposity or resistance to abdominal fat loss (difficulty losing belly fat)?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
Neuro-Endocrine & Longevity
29. Symptoms of hormonal imbalance (energy, mood, libido disruption)?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
30. Circadian rhythm disruption (poor sleep timing, shift work impact)?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
31. Unexplained weight fluctuation?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
32. Energy instability (crashes, especially after eating)?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
33. Thyroid-related symptoms (cold intolerance, hair thinning, sluggishness?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
34. Reproductive/endocrine concerns (cycle irregularity, menopause -- men & women, low testosterone)?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
35. Routine health tracking (weight, blood pressure, glucose, etc)?*

0

1

2

3

4

0 is Not at all, 4 is Persistent /Severe or Diagnosed
Health Background
Current health conditions, surgical, vaccinations.*
Family's Health History *
Current medications & supplemations
Top 3 Health Goals
Commitment and Priority
Willingness to follow the protocol*

YesNo
HIPAA Requirement: By proceeding, you acknowledge that your personal and health information may be collected, used, and stored for the purpose of assessment, consultation, and protocol delivery. Your information will be handled in accordance with applicable privacy standards and will not be share without your consent except as required by law.*

I have read and understand the HIPAA Privacy Notice and consent to the use and disclosure of my information as described.
Results
Thank you for completing the assessment. Your responses have been recorded and will be reviewed to determine the most appropriate next-step protocol.
Should be Empty:

Body Sings System Assessment

Client Baseline

Nervous System & Recovery

Full Body Optimization

Advanced Preventative

Cardio-Metabolic Optimization

Neuro-Endocrine & Longevity

Health Background

Commitment and Priority

Results