Tell us about yourself

What is your name?

What’s your e-mail?

Are you 18 years or older?

Yes No None

What gender do you identify with?

Male Female Non-binary Prefer not to answer None

Do you have any specific health goals?

Weight loss Craving control Sleep regulation Mental clarity Stress management Energy levels Mood control Overall health Cognition support

Other?

Do you often experience digestive issues such as bloating, gas, or indigestion?

Frequently Occasionally Never None

Have you been diagnosed with any metabolic conditions such as diabetes or thyroid disorders?

If yes, please speak to your PCP regarding health concerns

YES NO None

How would you rate your overall stress levels throughout the day?

High, often feel overwhelmed

Moderate, with occasional spikes

Low, rarely feel stressed

None

How would you describe your overall cognitive function and mental clarity?

Excellent, rarely experience brain fog or difficulty concentrating

Average, occasionally struggle with focus or memory

Poor, frequently experience brain fog and have difficulty focusing or remembering

None

Are you experiencing any of these?

If yes, please speak to your PCP regarding health concerns

Kidney or liver disease

Pregnant, breastfeeding, planning to get pregnant

None of the above

None

How motivated are you to improve your overall health through lifestyle changes and supplementation?

0 = not motivated at all, 10 = highly motivated

Would you like to schedule a free 15 minute consultation with a Registered Dietitian?

YES NO None

If yes, do you have any other specific concerns or questions you would like to discuss with the Registered Dietitian?