Body Signaling System Questionnaire

Body Signaling System Questionnaire

Take a few minutes and complete.
Your responses will be used to help create a curated support stack for the signals you are having. Signals are communication; through this, we can stop guessing what about body needs and really address what your body signals are trying to communicate.
All suggested supplements are third-party tested, made in FDA-inspected, GMP-certified facilities, and designed using bioavailable, plant-based ingredients. Each formula undergoes rigorous purity and potency testing — including checks for heavy metals, microbial contaminants, and ingredient stability — to ensure clean, effective, and reliable support you can trust.

This form is for general wellness guidance only and does not diagnose, treat, or cure any medical condition. The information you share helps provide a custom supplement suggestion using natural products only.

Always consult with your licensed healthcare provider before beginning any new supplement, especially if you are pregnant, nursing, on medication, or under medical care.
Name*

First NameLast Name
Email*
example@example.com
What town & State you live. This allows me to see if we have a Scan Partners near you. *
Low or inconsistent energyFeeling exhausted despite sleepingDifficulty falling sleep, staying asleep or waking up unrestedBrain Fog, forgetfulness, or mental fatigueMood swings or emotional sensitivityFeeling of anxiousness, restless, overwhelmed, or overstimulatedDifficuly maintaining attention or completing tasksLimited speech or delayed communication patternsEmotional outbursts or difficult regulating emotionsSensitivity to noise, light or touchHeart racing, fluttering of noticeable poundsTingling , numbness, pricking, tremors, or unusual body movementsDizziness or lightheadednessWeight gain or difficulty losing weightUnexplained weight lossStrong sugar or carb cravingsFrequent hunger or never feeling satisfiedBloating or abdominal pressureFeeling overly full or heavy after mealsConstipation or skipping days without eliminationLoose stools or urgent digestionHeartburn or burning sensations after eatingNausea or unsettled stomachFood sensitivities or reactions to certain foodsSudden aversion to foods previously toleratedJoint stiffness or discomfortMuscle tightness or frequent tensionHeadaches or head pressureSlow recovery after workoutsCold hands or feetShortness of breath during mild activityNight sweats or unusual sweatingFeeling overheated or sensitive to temperatureDry mouth or constant thirstFrequent urinationPuffiness, swelling or fluid retentionVisible veins, heavy legs, or leg discomfort after standingRectal discomfort, pressure or swellingChanges in libido or sexual desireIrregular, painful or unusually heavy menstrual cycleSkin changes (breakouts, rashes, dryness, irritation)Hair thinning, shedding, or brittle hairOpen sores or slow wound healingBruising easily or slow bruise recoveryYellowing of eyes or skinSwollen or tender lymph areas. (Neck, under arms or groin)Noticeable changes in body oder or sweat smellBlurred vision or visual disturbanceChronic throat clearing or lingering coughRestless in the legs at nightFrequent illness or slow bounce backGeneral sense that your body feels “off” or out of balance
On a scale of 1-10, how committed are you to making changes to your health right now *
Accountability and supportIdeas and support for movement/exerciseDoing a 1-3 day water fastTracking your food to know you are eating the right amountHelping getting in more protein and knowing how much I should be eating
I’m currently taking a collagen supplementI’m currently taking a vitamin supplementI’m currently taking a protein supplementI’m a coffee drinkerI’m curious about doing a body detox (gut, liver, kidney)
Of the signals you shared above that your body is giving you, which ones would make the biggest impact on your life if you were to improve them? What have you tried in the past or are you currently doing to help improve them?
I have a friend or two who might be interested in thisI’d like to learn more about being a Wellness Scan Partner
$100-150$150-$250$250+What ever I need to do, I just need to feel better
Thank you for taking the time to fill out the questionnaire. Please give me 24 hours to connect back and get you recommendations (typically it will be much sooner. I strive for 1 hour response time).
When you hit submit it will direct you to join the "BioScan Your Body" community where you can learn more and see testimonials.
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