Name(Required) First Middle Last Email(Required) Age(Required)Current weight(Required) Height(Required) Years of intense training experience?(Required) Any current injuries?(Required)Any history of surgeries or major procedures?(Required)Any food allergies? Foods to avoid? (This includes any negative reactions to gluten, dairy, sugar or alcohol)(Required)Please describe your current digestion and select the answer below that best applies to you:Frequency of Bowel Movements(Required)2 or more times daily1 time dailyless than once dailyFrequency of Constipation(Required)Every daya few times per weerarely everFrequency of Diarrhea(Required)Every daya few times per weerarely everFrequency of Heartburn, Acid Reflux, Hiccups(Required)Every daya few times per weerarely everFrequency of Bloating or After Meals(Required)All the timeoccasionallyrarely everFrequency of Burping or Gas After Meals(Required)All the timeoccasionallyrarely everWhen was your last blood work? If within the last 6 month please attach here(Required)Max. file size: 8 MB.On a scale of 1-10, please rate your current sleep quality and how many hours nightly on average? How many times do you wake up through the night? Do you wake up energized in the morning?(Required)Please describe your lifestyle and level of stress day to day?(Required)Do you own and use a smart watch that tracks total daily calories and activity? (Apple watch, fitbit, galaxy)(Required) Yes No Rough idea of current diet/macros?(Required)How many meals do you prefer to eat?(Required) Current training schedule and rep schemes?(Required)What time of day do you normally train?(Required) Current cardio regiment (if any) ?(Required)Current supplements used (otc and advanced)?(Required)Are you currently prescribed or using any medications including forms of Birth Control?(Required)Full History (if any) with advanced supplements? (dosages and timeline for use)(Required)Please score each question with the following correlating number to the answer that most accurately describes your current status: 1) None, 2) Mild, 3) Moderate, 4) Severe, 5) Extremely SevereDecline in your general well-being(Required)Chronic joint pain or muscular aches(Required)Excessive sweating(Required)Sleep problems(Required)Increased need for sleep, often feeling tired(Required)Irritability(Required)Nervousness(Required)Anxiety(Required)Physical exhaustion(Required)Decrease in muscular strength(Required)Depressive mood(Required)Feeling that you have passed your peak(Required)Feeling burn out, having hit rock bottom(Required)Feeling burn out, having hit rock bottom(Required)Decrease in ability/frequency to perform sexually(Required)Decrease in number of morning erections(Required)Decrease in sexual desire or libido(Required)Any other symptoms worth noting(Required)Under each category below, please mark as many as you feel relate to you either currently or previously.Category A: Please mark an “x” next to each statement you feel you identify with:(Required) I feel tired in the morning, even after a full night’s sleep. I depend on caffeine (coffee, energy drinks, etc.) to get through my day. I want to take naps most days. My energy crashes in the afternoon. I crave salty or sweet food. I’m dizzy when I stand up too quickly I feel at the mercy of stress. I have difficulty falling asleep and/or staying asleep. My muscles feel weaker. I get sick often and/or have a difficult time getting over infections. I have low blood sugar issues (Fasted Blood Glucose < 70 mg/dl). Category B: Please mark an “x” next to each statement you feel you identify with(Required) My life is crazy stressful. I feel overwhelmed by stress. I have extra weight around my midsection. I have difficulty falling or staying asleep. text box My body is tired at night, but my mind is going a mile a minute – I’m “wired & tired”. I get a second wind at night that keeps me from falling asleep. I wake between 2 and 4 AM and can’t go back to sleep. I feel easily distracted, especially while under stress. I get angry quickly or just feel on edge. I have high blood pressure or a fast heart rate. I have elevated blood sugar or diabetes I get shaky if I don’t eat often. I’m prone to injury and have difficulty healing. Category C: Please mark an “x” next to each statement you feel you identify with(Required) I have brain fog or feel like my memory isn’t quite what it used to be. I’m losing hair (scalp, body, outer third of the eyebrows). I’m constipated often and need a stimulant (like caffeine) or an OTC laxative to get a bowel movement. I’m cold and/or have cold hands and feet. I have joint or muscle pain. I have dry skin. I am in a low mood or struggle with depression I’m tired no matter how much I sleep. I find it difficult to break a sweat. I have recurrent headaches I have high cholesterol. I have a hoarse voice most days. Untitled Name First Last
