Intake

Just a moment

Opening your questionnaire.

About you

Step 1 of 7

About you

So the protocol is written for the right person.

Name

Date of birth Email

Location (city / state / country) Occupation

Height Weight

Main health goals

Your health concerns

Rank what matters most. There is more room for detail in the next step.

Main health concerns Top concern Second concern Third concern What you most want support with When symptoms began What makes symptoms better or worse

Symptoms

Add notes where something is going on. Tap not applicable to skip a row.

Energy & fatigue

Sleep

Stress & nervous system

Digestion

Bowels

Skin

Hair & nails

Muscles & joints

Headaches

Immune function

Hormonal health

Menstrual cycle

Menopause / perimenopause

Urinary health

Cardiovascular

Respiratory

Mood & emotional wellbeing

Blood work

Recent results are required. A phone photo or a PDF is fine. Multiple files are OK.

Current health information

Leave a row blank if it does not apply.

Current medications

Dose, duration, and reason.

Current supplements

Dose and frequency.

Previous diagnoses Previous surgery Significant illnesses Allergies or intolerances Relevant family history

Lifestyle

A typical picture is enough. Precision is not required.

Typical daily diet Protein, fruit and vegetable, and processed food intake Caffeine Alcohol Exercise Sleep Stress Work Relationships and social connection Time outdoors Hydration Smoking or vaping

Consent

Please read this before you send the intake.

Just a moment

Please pay first, then come back to the questionnaire.

Thank you. I have your intake.

About you

Your health concerns

Symptoms

Blood work

Current health information

Lifestyle

Consent