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Are you: MaleFemaleNon-Binary
What is your age?
What's on your mind? General HealthSpecific NeedDiscovery
What should we explore? BonesBrainDigestionEnergyFitnessHair / SkinHeartImmunitySleepStress
Do you have any skin concerns? DrynessHealthy SkinAgingGeneralComplexionNone
How are your bowel movements? Just RightNot EnoughToo OftenOther
Do you have a family history of heart disease? YesNo
Any Heart Concerns? CholesterolBlood PressureGeneral SupportNone
Do you have trouble falling asleep? YesNo
Do you sometimes feel tired when you wake up? YesNo
Do you sometimes feel burnt our or fatigued? YesNo
Do you sometimes get an afternoon energy slump? YesNo
Is your stress: Causing FatigueFeeling Burnt OutNeither
On an average day do you eat fruits and vegetables? RarelyOnce or TwiceThree or more times
On an average day do you eat dairy? RarelyOnce or TwiceThree or more times
On an average day do you eat protein? RarelyOnce or TwiceThree or more times
Do you have any allergies? EggsFishMilkPeanutsRagweedShellfishSoybeansTree NutsWheatNone
How would you describe your diet? Vegan / Plant BasedVegetarianMeatarianPescatarianAnything Goes
Do you have any other diet preferences or restrictions? Dairy FreeGluten FreePaleoKetoNo Preference
On average, how many times a week do you exercise? RarelyTwo or Three TimesFour or More Times
Your fitness routine includes: Resistance: yoga, pilates, or weightsHigh intensity: interval training, distance running, cyclingNone of theseI don't have a routine
When it comes to exercise you care most about: PerformanceBurning CaloriesBreaking a SweatGeneral Health
Do you have any of these fitness goals? Muscle ToningMuscle RecoveryMuscle BuildingNone
Do you experience muscle cramps after exercise? YesNo
Have you taken vitamins in the past? YesNo
How many vitamins or supplements do you take daily? None1 - 45+
Have you taken powders before? (Protein, Maca, anything mixed into a drink) YesNo
If yes, on average how many times a week do you take powders? RarelyA Couple of DaysMost DaysDaily
Are you interested in prenatal or postnatal supplements? YesNo
NOTES: ( please list any pre-existing condition and medications)