Name

Hi! What’s your lovely name?

health habits

None

How many supplements are you currently taking?

18-29

30-49

How old are you?

Gender

Female

Male

What is your gender?

Select your top 2 goals that you want to work on first?

Goals

Immunity

Sleep 

Fitness

Stress 

Energy 

Digestion

Brain

Hair. Skin, Nails

Heart 

Joints & Bones

Weight management

Pregnancy & Postpartum

Deficiency

Maintenance 

Choose your health goals. 

Select as many as you like, but we recommend you select your top 2

Sleep

Fitness 

Stress

Digestion 

Heart

Maintenance

Are you surrounded by children or adults with sensitive immunity?

Do you experience seasonal sinus or lung issues?

Yes in the past 6 months

No I haven’t used antibiotics in the past 6 months

Have you used antibiotics in the last 6 months?

Do you have trouble sleeping?

Do you wake up often when you are asleep?

Did you recently come back from a different time zone?

Not at all

once or twice

3+ a week

How often do you find yourself stressed in a week?

rarely

two to four times

 five or more times

On average how often do you exercise a week?

Weight Lifting

Pilates 

Endurance

High Intensity

Yoga 

none of these

What does your fitness routine consist of?

I want to maintain my health and my strength

I want more muscle mass and size

I want help with recovery after my training

I want to perform better in the workout

I want to protect and strengthen my joints

How can we help you achieve your fitness goals?

Energy

Do you find yourself experiencing afternoon fatigue?

It’s the normal- high in the morning low at night

high throughout the day

low in the morning high at night

inconsistent

How would you describe your energy cycle?

less than once a day

once a day

more than once a day

Which best describes your bowel movements?

bloating

burping

indigestion

none

Do you regularly feel/experience any of the following?

Do you sometimes have trouble focusing or concentrating on specific tasks?

Do you sometimes experience brain fog?

Do you find yourself sometimes struggling with short-term memory?

Hair, Skin, Nails

uneven

dull

smooth and hydrated

my skin is great

How does your skin generally feel?

Breakouts

hyperpigmentation

wrinkles

elasticity

From the options below please select your skin concerns:

thinning

feels brittle and dry

split ends and damage

growing but very slowly

my hair is perfect

Which of the following describes your hair?

strengthen

grow

 treat spots

nothing

When it comes to nails are you looking to:

Any family history of heart problems?

cholesterol

blood pressure

neither

Which of the followings are your heart concerns: 

Often

Very often

How often do you experience  discomfort in your joints?

Do any of your family members have bone problems?

Do you feel any discomfort going up and down the stairs?

Weight Management

Do you struggle with losing and gaining weight?

Do you find yourself often craving sweets?

Please note that any change in diet or supplementation while trying, during pregnancy, and postpartum should always be discussed with your practitioner.

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