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METABOLIC HEALTH ASSESSMENT
Apply here
First name
*
Last name
*
Email
*
Phone
Do you experience any of the following?
Fatigue
Energy crashes
Brain fog
Mood swings
Irritability
Anxiety
Depression
Weight gain
Difficulty losing weight
Belly fat
Bloating
Cravings sugar
Cravings carbs
Afternoon cravings
Midnight snacking
Need to eat every 2-3 hours
Hangry between meals
Tired after eating
Need caffeine to function
Afternoon slump
Wake up tired
Trouble falling asleep
Wake up 2-4am
Restless sleep
Vivid dreams
Night sweats
Cold all the time
Dark skin patches
Skin tags
Adult acne
Slow healing cuts
Hair loss
Thinning hair
Facial hair growth
Irregular periods
Heavy periods
Missing periods
PMS symptoms
Low libido
Fertility Issues
PCOS
Endometriosis
Thyroid issues
High blood pressure
High cholesterol
Heart palpitations
Chest pain
Shortness of breath
Dizziness standing up
Frequent infections
Cold and flu often
Slow immune recovery
Autoimmune conditions
Lupus
Celiac disease
Inflammatory bowel disease IBS
Food Allergies
Allergies
Asthma
Eczema / Psoriasis
Rashes
Digestive issues
Constipation
Diarrhea
Gas
Heartburn
Acid reflux
SIBO
Nausea
Stomach pain
Gluten sensitivity
Dairy sensitivity
Joint pain
Headaches
Migraines
Chronic pain
Chronic fatigue
Memory issues
ADHD
Kidney stones
Gallstones
Prediabetes
Diabetes Type 1
Diabetes Type 2
Joint Pain
Osteoporosis
Anemia
Cancer history
Heart disease
Stroke
Varicose veins
Circulation issues
Vision changes
Hearing changes
Balance issues
Other
What's your #1 health goal right now? What made you decide to reach out for help NOW?
Previous attempts at improving health (what worked/didn't work?)
Describe a what to do for fun / relaxation
Describe a what to do for exercise
Describe a typical day of eating
List the healthy food/drinks that you commonly have
List your favorite comfort/cheat day food/drinks
Current medications/supplements
Family history of diseases/Illnesses
Multi choice
Plastic food containers
Plastic water bottles
Non stick cookware
BPA cans
Tap water
Non organic foods
GMO foods
Gluten / Bread /Pasta
Sugar
Honey / Agave
Vegetable oils
Deli / Cured Meat
Household cleaners
Air fresheners
Scented candles
Perfume daily
Fabric softener
Laundry detergent chemical
Shampoo sulfates
Scented Body products
Toothpaste fluoride
Deodorant aluminum
Makeup daily
Sunscreen
Lawn chemicals
Chlorine pools
New carpet
New furniture
Dry cleaning
Synthetic fabrics
City air pollution
Mold exposure
Water damage mold
Microwave frequent use
Fluorescent lights
Computer screens long
Phone screens long
X rays frequent
CT/ MRI / Scans
Dental amalgams
Root canals
Antibiotics frequent
Birth control pills
Pain relievers frequent
Energy drinks
Restaurant food frequent
Packaged foods
Granola bars
Protein bars
Breast Implants
Submit
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