Clone of Deep Dive Health Assessment

GutStrong Application

GutStrong is for women 50-yrs and over who are ready to make real change — not chase quick fixes
These questions help me assess whether you’re a good fit right now and whether I can confidently support you to get results.

The application process starts with this form, which will take you approx. 30-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 - You must be 50-yrs and over to apply*

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

Health, Medications, Supplements, Procedures

This provides us with a brief understanding of the health issues you are facing
List ALL your CURRENT 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 your CURRENT prescribed medications (including contraceptives, weight loss injections etc). If NONE, please type in NONE*
Using ONE line per each... List ANY over-the-counter drugs (e.g. Nurofen, Panadol Antacids, Anti-histamines etc.) you are CURRENTLY taking (even if sporadic). 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 and alcohol) and how frequently you have. If NONE, please type in NONE*
Using ONE line per Supplement i.e. pills, powders, tonics etc. List ALL supplements that you CURRENTLY take (even if sporadic) and how often. If NONE, please type in NONE*
List any facial or body 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"

Commitment & readiness
Why does making these changes matter to you right now, and what’s motivating you to commit to 'making change' at this stage of your life?*
What’s happening in your health/life that makes you ready to address this now?

Disclosure and Agreement
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