Clone of Deep Dive Health Assessment

GutStrong Application
GutStrong is an application-only program because we care deeply about outcomes.

This program asks for commitment, participation, and openness to change.
It works best when it’s the right fit for both you and us.

The application process starts with this application, which will take you approx. 15-minutes to fill in.

After you submit your form, you'll get an email with the next steps.

We believe this respectful, transparent approach protects your time, energy, and investment.
Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
State/ Province you live in...*
Suburb or Town you live in...*
Email Address*
example@example.com
Mobile/Cell Number*

Country CodeMobile/Cell Number
Your occupation. (If retired, please write previous occupation and the words 'retired')*

Health, Medications, Supplements, Procedures

This provides us with a brief understanding of the health issues you are facing
List ALL your health issues, conditions, disorders etc. (even little niggles) you are CURRENTLY experiencing AND what year it started*
Using ONE line per each... List all prescribed medications (including contraceptives) AND any over-the-counter drugs (e.g. Nurofen, Panadol etc.) you are currently taking (do NOT list supplements) If NONE, please type in NONE*
Using ONE line per each... List any prescribed drug (e.g. medicinal cannabis) or recreational drug (incl. cigarettes/vaping) you use and how often. If NONE, please type in NONE*
Using ONE line per Supplement i.e. pills, powders, tonics etc. List all supplements that you take (even if sporadic) and how often. If NONE, please type in NONE*
List any facial or body rejuvenation procedures you have undertaken, now or in the past (i.e. Botox, fillers, gastric sleeve, lap band, liposuction etc.) If none, type in NONE*
Measurements
Height (in centimetres)… Please do NOT estimate*
Just enter the number NOT the word "cm"
Weight (in kilograms)… *
Just enter the number NOT the word "kg"
Waist (in centimetres)… Measure at the narrowest part of your waist. *
Just enter the number NOT the word "cm"

Blue-Sky Future
If you had NONE of your current health challenges what would your 'blue-sky" future look like...
1. What would you be able to do, enjoy, or experience?
2. How would you feel in your body each day?
3. How would you look?
4. What would life look like in the next 5, 10, or even 30 years of your life?
Write your answers here...*
Why does making these changes matter to you right now, and why are you committed to 'making change' at this stage of your life?*
Disclosure and Agreement
I certify that I have disclosed all health issues, conditions and disorders, have answered truthfully and have not omitted any information.*

YesNo
By typing my name BELOW I acknowledge I have read, understood and agree to the Terms and Conditions and I am signing this form under the Electronic Transactions Act 1999 Section 10 - Signatures
Please sign in the box below*

Clear
Please verify that you are human*
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GutStrong Application