Name *

First Name

Last Name

Phone *

(###)

###

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▻ Communication Preference: Would you like to be added to my VIP text list for updates and promotions? *

Yes please

No thank you

▻ I feel tired more often than not:

Yes

No

▻ I wish I felt more motivated to do certain activities:

Yes

No

▻ I often feel disengaged and distracted:

Agree

Disagree

▻ I have frequent mood changes (quick to anger/depression/anxiety):

Agree

Disagree

▻ I have trouble falling asleep / staying asleep:

Agree

Disagree

▻ On average, how much quality sleep do you get per night?:

2 - 4 hours

4 - 6 hours

6 - 8 hours

8 - 10 hours

▻ I have extreme food cravings (e.g. sugar) or would like to change my eating habits:

Agree

Disagree

▻ After eating, I typically feel bloated/have a hard time digesting my meals:

Daily

2-3 times per week

Once Per Week

Rarely

▻ What is your current level of physically activity?

Sedentary

Light Activity

Moderate Activity

Vigorous Activity

▻ How often do you exercise per week?

Rarely

1 - 2 Times

3 - 4 Times

5 or More

▻ I would like to improve my body composition:

Lose Fat

Gain Muscle

Both!

I am satisfied with my Body :)

▻ I struggle with skin irritations (e.g., acne, eczema, psoriasis, ect.):

Agree

Disagree

▻ How would you describe your skin?

Oily

Dry

Combination

Sensitive

▻ I occasionally/often have headaches/migraines:

Agree

Disagree

▻ I struggle with autoimmune issues )e.g., thyroid issues, rheumatoid arthritis, multiple sclerosis, type 1 diabetes, ect.):

Yes

No

▻ I struggle with libido/reproductive health/menopause/painful periods:

Agree

Disagree