Personal Info

First Name:
Last Name:
Email:
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Age:
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Digestion/Absorption

Does food feel like it stays in your stomach for a long time after eating?

Does eating cause nausea, cramps, heartburn, or feel like your food isn’t digesting properly?

Do you experience frequent diarrhea?

Do you experience frequent constipation?

Do you frequently burp or have gas within an hour after eating?

Have you noticed pieces of undigested food in your stool?

Dysbiosis Inflammation

Have you ever experienced diarrhea, upset stomach, or vaginal discomfort after taking antibiotics?

Do you regularly experience bloating or gas?

Do you feel tired or mentally foggy after eating?

Have you been diagnosed with or suspect you have IBS (Irritable Bowel Syndrome), IBD (Inflammatory Bowel Disease), or SIBO (Small Intestinal Bacterial Overgrowth)?

Have you been diagnosed with or suspect you have an autoimmune condition (like Hashimoto’s, rheumatoid arthritis, lupus, etc.)?

Do you experience acid reflux, heartburn, or GERD?

Nutritional Cellular Health

Are you currently overweight or obese?

Do you eat fast food more the once per week?

Do you eat fewer than 5 servings of fruits and vegetables daily?

Are you vegetarian or vegan?

Do you frequently crave sweets?

Do you often crave fried or fatty foods?

B-Vitamin Deficiency

Do you get leg cramps at night?

Do you often feel tired or low on energy?

Do you experience numbness or tingling in your hands or feet?

Have you been diagnosed with bone loss or osteoporosis?

Do you have a history of anemia?

Do you get cracks or sores at the corners of your mouth?

Liver/Gallbladder

Do you get loose stools after eating fatty foods?

Do you notice light or clay-colored stools, coated tongue or bad breath?

Are your stools greasy or shiny?

Do you drink alcohol?

Do you use artificial sweeteners?

Have you noticed yellowing of your eyes or skin, or frequent skin rashes?

Thyroid Insufficiency

Do you often feel cold, or have cold hands and feet?

Is your skin dry or your hair dry and brittle?

Have you gained weight without explanation or had trouble losing weight despite trying?

Do you struggle with ongoing constipation?

Are you experiencing excessive hair loss or coarse, thinning hair?

Have you lost the outer third of your eyebrows?

Adrenal/Melatonin Insufficiency

Do you feel dizzy when standing up too quickly?

Do you experience low blood sugar symptoms like shakiness, irritability, or sweating?

Have you been under prolonged stress or working long hours?

Do you feel a slump or crash in energy during the afternoon?

Do you often wake up between 3:00–5:00 AM?

Do you frequently crave salty foods?

Connective Tissue & Vasculature

Do you get skin ulcers or sores on your legs or feet?

Do you have varicose veins or spider veins?

Do you bruise easily or get black-and-blue marks often?

Do you experience frequent nosebleeds?

Do you get short of breath easily?

Do you have blood sugar swings or symptoms of low blood sugar?

Blood Sugar & Body Comp

Has your fasting blood sugar ever been over 100?

Have you been diagnosed with prediabetes or diabetes?

Do you carry excess weight around your belly?

Do you often crave sweets?

Do you feel lightheaded, irritable, or shaky if you miss a meal?

Do you feel tired or sluggish after eating?

Immune Health

Do you often have nasal congestion or post-nasal drip?

Do you have frequent digestive upset, bloating, or irritable bowels?

Have you been diagnosed with asthma, eczema, psoriasis, migraines, or an autoimmune condition?

Do you get chronic infections (e.g., sinus, urinary, or respiratory)?

Do you catch colds or the flu more often than others?

Do you feel chronically fatigued, even after rest?

Hormone Imbalance

Do you struggle with slow metabolism or unexplained weight gain?

Has your sex drive significantly decreased?

Do your muscles feel weak or less toned?

Do you notice sagging skin or a loss of skin firmness?

Do you experience frequent or stubborn acne?

Are you experiencing noticeable hair loss?

Joint/Muscle Inflammation

Do your joints feel stiff when you wake up?

Do joint or muscle pains limit your daily activities?

Do you notice swelling or warmth around your joints?

Have you experienced a decrease in your range of motion?

Are you less flexible than you used to be?

Do your joints feel tender when you press on or near them?

Lipid Metabolism

Have you been told you have high cholesterol or high LDL ('bad') cholesterol?

Do you have high triglyceride levels?

Do you have low HDL ('good') cholesterol?

Do you carry extra weight around your belly?

Have you been diagnosed with fatty liver?

Have you had your gallbladder removed?

Cardio-Dynamics

Have you been diagnosed with high blood pressure?

Do you get lightheaded or dizzy when climbing stairs or exerting yourself?

Do you have a sedentary lifestyle (little to no exercise each week)?

Do you experience chest pain?

Do you often feel short of breath?

Do your feet or ankles swell regularly?

Kidneys/Renal

Do you experience frequent bladder irritation or discomfort?

Do you have a history of kidney stones?

Is your urine usually dark in color?

Does your urine often smell bad or appear cloudy?

Do you frequently feel a strong or urgent need to urinate, or have a weak urine stream?

Do you feel burning or pain when urinating?