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What brings you here today?
Tell me why you came.
What are your top three health concerns you would like support with (be specific)?
*
How long have you been experiencing these symptoms?
*
Less than 6 months
6 months to 2 years
More than 2 years
What are you hoping to accomplish through this program?
*
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Personal Information
Name
*
First Name
Last Name
Age
Weight
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Current Health
Have you been told you have any of the following?
*
High blood pressure
Prediabetes
Type 2 diabetes
Insulin resistance
PCOS
Fibroids
Thyroid condition
Fatty liver
Autoimmune condition
High cholesterol
Digestive disorder
Other
Current Medications
*
Current Supplements
*
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Lifestyle Snapshot
Approximately how many hours of sleep do you get each night?
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Less than 5
5-6
7-8
More than 8
How would you describe your energy?
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Excellent
Good
Fair
Poor
How often do you exercise?
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Daily
3-5 times a week
1-2 times a week
Rarely
How much water do you drink daily?
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Less than 32 oz
32-64 oz
More than 64 oz
How often do you prepare most of your meals at home?
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Almost always
Oten
Sometimes
Rarely
How often do you typically eat ultra-processed foods (such as packaged snacks, frozen meals, fast food, or sugary drinks)?
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1-2 times per week
3-5 times per week
Almost everyday
On a typical day, how many servings of vegetables do you eat?
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0-1
2-3
4+
What time do you go to bed?
*
By 10pm
10-11pm
After 11pm
How would you rate your stress level (Low → High)?
1
2
3
4
5
How often do you have bowel movements?
*
Less than once daily
1-2 times daily
3 times daily
More than 3 times daily
using the above chart, which number best represents your bowel movements?
*
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
Type 7
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Symptoms
Check any that apply.
Energy
*
Fatighe
Afternoon crash
Difficulty concentrating
Brain fog
Digestion
*
Bloating
Gas
Constipation
Diarrhea
Reflux
Food sensitivities
Blood Sugar
*
Strong sugar cravings
Hungry shortly after eating
Shaky if meals are delayed
Sleepy after meals
Hormones
*
Irregular cycles
Heavy periods
Painful periods
Acne
Hair thinning
Excess facial hair
Hot flashes
General
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Joint pain
Poor sleep
Anxiety
Depression
Frequent infections
Difficulty losing weight
Swelling
Skin issues
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Which areas do you feel need the most improvement? Check your top three
*
Nutrition
Hydration
Sleep
Movement
Stress management
Digestion
Bowel regularity
Time outdoors
Meal planning
Consistency
Symptom support
Brain Health
Which of these areas do you feel most confident about?
*
Nutrition
Sleep
Movement
Stress management
Digestion
Hydration
None yet
How would you rate your mental health?
*
Low
Fair
Good
Excellent
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What do you believe has been the biggest obstacle to improving your health?
*
What lifestyle changes have you already tried?
*
Is there anything else you would like me to know?
*
Appointment
Reserve Your Appointment
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