🧠 MIND + MOOD

1. How often do you feel anxious, moody, or emotionally “off” even when life is fine?

Rarely/Never

Sometimes

Often

🧠 MIND + MOOD

2. Do you struggle with focus, brain fog, or mental exhaustion during the day?

Rarely/Never

Sometimes

Often

🍽 DIGESTION + FOOD RESPONSE

3. How often do you feel bloated, gassy, or uncomfortably full after meals?

Rarely/Never

Sometimes

Often

🍽 DIGESTION + FOOD RESPONSE

4. Have you noticed new or worsening food sensitivities/reactions?

Rarely/Never

Sometimes

Often

🍽 DIGESTION + FOOD RESPONSE

5. Are your bowel movements inconsistent (loose, hard, urgent, etc.)?

Rarely/Never

Sometimes

Often

💤 ENERGY + SLEEP

6. Do you wake up tired, even after a full night’s sleep?

Rarely/Never

Sometimes

Often

💤 ENERGY + SLEEP

7. Do you get mid-day crashes or feel like you “hit a wall” in the afternoon?

Rarely/Never

Sometimes

Often

💤 ENERGY + SLEEP

8. How often is your sleep disrupted (falling asleep, staying asleep, or both)?

Rarely/Never

Sometimes

Often

🩺 SKIN, IMMUNE & INFLAMMATION

9. Do you get frequent headaches, joint stiffness, or unexplained aches?

Rarely/Never

Sometimes

Often

🩺 SKIN, IMMUNE & INFLAMMATION

10. Do you experience skin issues (rashes, acne, flare-ups)?

Rarely/Never

Sometimes

Often

🩺 SKIN, IMMUNE & INFLAMMATION

11. Do you get sick often or struggle with lingering symptoms after a cold/virus?

Rarely/Never

Sometimes

Often

⚖️ WEIGHT + METABOLIC SHIFTS

12. Are you gaining weight or struggling to lose it despite no major changes?

Rarely/Never

Sometimes

Often

⚖️ WEIGHT + METABOLIC SHIFTS

13. How often do you crave sugar or carbs?

Rarely/Never

Sometimes

Often

⚖️ WEIGHT + METABOLIC SHIFTS

14. Do your hormones feel “off” (mood swings, cycle changes, hot flashes)?

Rarely/Never

Sometimes

Often

Full Name

Phone *

Email *

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