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)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) I’m emotionally fragile and/or I feel nostalgic about the past. I have difficulty with memory. My periods are shorter than 3 days. I struggle with depression, anxiety, lethargy. I experience night sweats and/or hot flashes. I’ve had trouble with recurrent bladder infections I sometimes have problems with urinary leakage I have difficulty sleeping and wake up in the middle of the night. My breasts are smaller and/or beginning to droop. I have achy joints or am prone to joint injuries. My sun-damaged skin is more noticeable I am noticing more fine lines and wrinkles. I have dry or thinning skin. I have no interest in sex. I have vaginal dryness or pain with intercourse. Category C: Please mark an “x” next to each statement you feel you identify with(Required) I experience PMS seven to ten days before my period. I get headaches or migraines around my period. I feel anxious often. I have painful, heavy, or difficult periods. My breasts are painful or swollen before my period. I feel agitated, irritable, or weepy before my period. I have had a miscarriage in the first trimester. I experience restless legs, especially at night. I have had difficulty getting pregnant (after trying for six or more months) Category D (Women Only): Please mark an “x” next to each statement you feel you identify with(Required) I have abnormal hair growth on my face, chest, and/or abdomen. I have acne. I have oily skin and/or hair. I have areas of darker skin (e.g., armpits, upper inner thighs near groin) I’ve noticed thinning hair on my head. I have skin tags. I struggle with depression and/or anxiety. I have been medically diagnosed by my PCP or OB/GYN with PCOS. I have had difficulty getting pregnant (after trying for six or more months). Category E: Please mark an “x” next to each statement you feel you identify with(Required) I have a low libido or diminished sex drive. I struggle with depression, have mood swings, or cry easily. I have no motivation. I am tired or fatigued throughout the day or have been diagnosed with chronic fatigue syndrome. I’m unable to gain muscle, and I’m losing muscle mass. I have a decrease in bone density or have been diagnosed with osteopenia or osteoporosis. I have urinary incontinence. I have a loss of sexual fantasies. I have difficulty or am unable to orgasm. I have cardiovascular symptoms of heart disease. I struggle with weight gain despite attempting to eat healthy and exercise. have anxiety or experience panic attacks. Category F: 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 G: 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. My body is tired at night, but my mind is going a mile a minute – I’m “wired and 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 H: 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). My hair is dry and tangles easily. 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 My periods are sporadic or occur more than thirty-five days apart. I have joint or muscle pain. I have dry skin. I have had difficulty getting pregnant (after trying for six or more months) or have had a first trimester miscarriage. 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 Untitled Name First Last Name First Last
