Genetic Needs Assessment

1
Have you struggled with yo-yo dieting or unwanted weight gain?* This field is required.
YESNO
2
Are you exhausted, waking without feeling rested, or crashing in the afternoon?* This field is required.
YESNO
3
Do you consider your genetic requirements when it comes to nutrition?* This field is required.
YESNO
4
Do you spend 15 minutes or more each day thinking about the following?* This field is required.Select all that apply
Weight
Gut health
Energy Levels
Hormone health
Your relationship with food
All of the above
5
Where do you carry most of the weight?* This field is required.Select all that apply
Abdomen
Legs
Arms or back
Face
Full body
I need to gain weight
6
Have you experienced any of the following in the past 3 months?* This field is required.Select all that apply
Constipation
Food sensitivities or allergies
Diarrhea
Bloating
Gas
Other
7
Do you experience any of the following?* This field is required.Select all that apply
Hot flashes
Irritability or PMS
Acne or dryness
Sleep disturbances
Menstrual irregularities
Other
8
Have you been diagnosed with any of the following?* This field is required.Select all that apply
Thyroid disorder
PCOS
Peri/Menopause
Adrenal fatigue
Pre/Diabetes
Other
9
Do you struggle with any of the following?* This field is required.Select all that apply
Bingeing or purging
Chronic restriction
Fixation on healthy eating
Living for cheat meals
Emotional or stress eating
Other
10
Do you live with any of the following?* This field is required.Select all that apply
High stress
Anxiety or depression
Dehydration
Lack of sleep
Anemia
Nutrient deficiencies (B12, etc)
11
Which of the following Juniper Nutrition outcomes are you most interested in?* This field is required.Select all that apply
Permanent weight loss
Healthier gut
Balanced hormones
Optimal energy levels
Healthy relationship with food
All of the above!
12
How ready do you feel to begin making changes for your health? * This field is required.Remember, you were brave enough to start. There's no wrong answer!
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13
Please provide your contact information* This field is required.We’ll be in touch within 24 hours with key insights/recommendations!
Full Name
Email
Telephone
Please Select
Please Select
Telephone
Email
Preferred method of contact
Instagram handle
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