-
-
- Preferred Contact Method*
-
-
-
Format: (000) 000-0000.
-
Format: (000) 000-0000.
-
-
-
-
-
- What is your PRIMARY wellness goal?*
- What support do you need right now?*
- Any secondary goals? (select all that apply)*
-
-
-
-
-
-
-
- Do you have body composition data available?
-
-
- Do you snore?
- Has anyone noticed pauses in your breathing during sleep?
- Do you have morning headaches, dry mouth, or both?
- Do you use CPAP or BiPAP?
- Do you use devices or screens before bed?
- Energy Pattern
- In the past 2 weeks, have you experienced any of the following?
- What has stopped you from reaching this goal before?*
-
-
- How often do you eat protein-rich foods?
- How often do you eat fruits and vegetables?
- How often do you eat ultra-processed foods?
- Do you eat late at night?
- Which cravings do you notice most often?
-
- How severe are your allergy or intolerance symptoms?
-
- Which of the following medications do you currently take?
-
- Do you have any medication allergies?
-
- Which health conditions have you been diagnosed with?
-
- Family history
- Have you had bloodwork in the last 6 months?
- Would you be willing to complete bloodwork if recommended?
-
-
-
-
-
- Do you have trouble falling asleep?*
- Do you wake during the night and struggle to go back to sleep?*
- Do you feel rested when you wake up?*
-
-
- When do you experience your lowest energy?
-
- What are your main sources of stress?
- Do you have a current stress management practice?
- Do you consume caffeine?*
-
-
- What types of exercise do you do?*
-
- Do you use a wearable device?
- Do you have any injuries or physical limitations?*
-
-
-
-
-
-
- Do you have any food allergies or intolerances?*
-
-
- Are you currently taking any supplements?*
-
- Are you currently taking any prescription medications?*
-
- Energy Symptoms
- Digestive Symptoms
- Mental & Cognitive Symptoms
- Mood Symptoms
- Physical Symptoms
- Weight & Metabolism Symptoms
- Sleep Symptoms
-
-
-
-
- Should be Empty: