Your order ID
What is the number one thing I can help you with?
What are your health and fitness goals:
What is the greatest obstacle that’s preventing you from
achieving these goals:
Do you have a medical condition:
Medication (list dosage of prescription and or recreational drugs
Supplements (list dosage and supplement taken regularly):
Do you have any diagnosed issues with your hormone function:
How much water do you consume/day:
How many hours of sleep do you get/night:
Do you smoke or drink alcohol regularly?
Do you often feel irritable and tired?
Women, is your period regular?
Women, have you gone through or do you suspect you are going
How much caffeine do you consume daily (coffee, pre-workouts,
thermogenics, soda, tea..)?
When was your last hormone panel? If you have labs from the
past 6 months please included them for my review.
On a scale to 1-10 how healthy is your relationship with food? If
under 5 please elaborate.
Weekly Activity (type, time and duration of exercise daily):
When was your last hormone panel? If you have recent labs (6 months) please email them to firstname.lastname@example.org
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