First Name

Last Name

Email *

Gut

Do you experience daily bloating, constipation, diarrhea, or food sensitivities?

Never

Rarely

Sometimes

Always

Have you been diagnosed with allergies, acne, or an autoimmune condition?

Never

Rarely

Sometimes

Always

Adrenals

Do you often feel drained throughout the day or crash if you miss a meal?

Never

Rarely

Sometimes

Always

Do you crave salty foods or feel lightheaded when standing up too quickly?

Never

Rarely

Sometimes

Always

Hormones / Thyroid

Do you struggle with low libido, irregular periods or erectile issues, or thyroid imbalance?

Never

Rarely

Somtimes

Always

Do you feel a crash or energy dip after eating carbs or sugar?

Never

Rarely

Sometimes

Always

Infections

Do you feel flu-like fatigue when under stress, or get sick often?

Never

Rarely

Sometimes

Always

Have you ever had mono, shingles, or other chronic viral infections?

Never

Rarely

Sometimes

Always

Stress

Do you feel unhappy or dissatisfied with your personal or professional relationships?

Never

Rarely

Sometimes

Always

In the past month, have you felt overwhelmed, anxious, or like challenges are piling up?

Never

Rarely

Sometimes

Always

Structural

Do you tend to hold tension in your neck and shoulders, or experience headaches or back pain?

Never

Rarely

Sometimes

Always

I feel uncoordinated or like one side is working different than the other.

Never

Rarely

Sometimes

Always

Toxins + Detoxification

Are you sensitive to chemicals, fragrances, or experience symptoms like brain fog or nausea from poor air or product quality?

Never

Rarely

Sometimes

Always

Have you had significant exposure to toxins like pesticides, cigarette smoke, or mold?

Never

Rarely

Sometimes

Always

Mitochondria

Do you feel deeply fatigued after exercise or struggle to build stamina and strength?

Never

Rarely

Sometimes

Always

Do you experience brain fog or feel mentally slow or drained?

Never

Rarely

Sometimes

Always

Cellular

Despite healthy habits, do you feel like something is still missing in your healing?

Never

Rarely

Sometimes

Always

Mindset

Do you often doubt your potential, shut down emotionally, or find it hard to stay consistent when you start something new?

Never

Rarely

Sometimes

Always

Energy Systems / Spiritual

Do you feel disconnected from your intuition or energy, struggle to quiet your mind or meditate, or notice repeated life patterns pushing you toward change?

Never

Rarely

Sometimes

Always

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