Welcome

1

NameLet’s get going!

First Name

Last Name

2

EmailYour results will be sent via email!

example@example.com

3

Date of birth:

Date

4

Height and Weight

Height

Weight

5

How many hours of sleep do you get on average?

6

Do you wake up feeling rested?

YESNO

7

Do you experience difficulty falling or staying asleep?

YESNO

8

How would you describe your daily energy levels?

9

What types of exercise do you do? Check all that apply

10

Do you experience exercise-induced fatigue or difficulty recovering from workouts?

YESNO

11

How would you describe your stress levels?

12

What are your primary sources of stress?Check all that apply

13

Do you practice any stress management techniques?(e.g., meditation, breathwork, journaling, yoga, therapy) Please list them below, if so.

14

How would you describe your eating habits?

Balanced and nutrient-dense

High-carb, low-fat

Low-carb, high-fat (e.g., keto)

High protein

Vegetarian or Vegan

Inconsistent or emotional eating

15

How often do you consume processed or fast food?

Rarely or never

1-2 times per week

3-4 times per week

Daily

17

Do you consume alcohol

No

Occasionally (1-2 drinks a month)

Regularly (1-2 drinks per week)

Frequently (3+ drinks per week)

18

Do you consume caffeine

No

1 cup per day

2-3 cups per day

4+ cups per day

19

Do you take any supplements or vitamins?Please list them below

20

Do you have any dietary restrictions, food sensitivities, or allergies?If Yes please specify (Click "Next" if No)

22

When did these symtoms first begin?

23

Have you noticed any patterns in your symptoms?(e.g., around your period, during ovulation, under stress)

24

Do you have a menstrual cycle?

Yes

No (e.g., menopause, hysterectomy)

25

How long is your typical cycle?

21-25 days

26-30 days

31+ days

Irregular

26

Do you experience any of the following menstrual symptoms?Check all that apply

Heavy bleeding

Painful cramps

Spotting between periods

Clotting

PMS (mood swings, cravings, bloating)

None

27

Have you experienced any reproductive health issues?If Yes, please specify. (If no, please click "next")

28

Have you experienced perimenopause or menopause symptoms?

Yes

No

Unsure

29

Do you have any diagnosed medical conditions?If Yes, please specify. (If no, please click "next")

30

Are you currently taking any medications?If Yes, please specify. (If no, please click "next")

31

Do you have a family history of hormonal or metabolic issues?(e.g., thyroid disorders, diabetes, PCOS, breast cancer)

32

Is there anything else you’d like me to know about your health, goals, or symptoms?