Please Read Carefully:

Our Whole Body Hormone Solution™ program includes a personalized roadmap built on advanced diagnostics, expert guidance, and integrative therapies.

Our program has 2 parts. The first, The Hormone Clarity Protocol, includes advanced testing and diagnostics to uncover the root cause of your hormonal imbalance. In Part 2, The Ultimate Hormone Reset, we effectively treat your hormonal imbalance.

Sophisticated Diagnostics: Includes comprehensive hormone, gut, blood, and metabolic testing—far beyond standard labs—to uncover the true root causes of your symptoms.

Tailored Treatment Plan: Every protocol is fully customized to your unique biology, lifestyle, and goals—no guesswork, no generic plans, just precision-based healing.

Premium-Level Support: Over 20+ one-on-one visits with your functional medicine doctor, health coach, acupuncture specialist, and organic aesthetician for an unparalleled, high-touch experience.

This form takes just 10 minutes—and could mark the beginning of a profound shift in your health, energy, and confidence.

1. Personal Information

2. Are you ready to commit to a journey of true healing?

Are you to commit to lasting transformation—not just short-term fixes?

Program involves follow-up visits, coaching sessions, and acupuncture/body treatments spaced over 6–8 months. Can you consistently commit time for these touchpoints?

In a position to invest in a comprehensive, high-touch wellness *program?

*This is a premium investment in your long-term vitality, starting at $3,499 for Part 1, The Hormone Clarity Protocol, with the option to continue into our exclusive 6-8 month whole body transformation program, The Ultimate Hormone Reset, which includes specialized treatment protocols to get you feeling like yourself again.

3. What Are Your Main Health Concerns?

(List your top concerns in order of priority)

How severe?

Mild

Moderate

Severe

What Have You Tried?

Did It Work?

Yes

Somewhat

How severe?

Mild

Moderate

Severe

What Have You Tried?

Did It Work?

Yes

Somewhat

How severe?

Mild

Moderate

Severe

What Have You Tried?

Did It Work?

Yes

Somewhat

4. How Is This Affecting Your Life?

How Is This Affecting Your Life? *

My energy & ability to get things done

My ability to focus & think clearly

My mood & emotions (irritability, anxiety, depression)

My sleep & recovery

My weight & metabolism

My confidence in my body

My relationships with others

My ability to enjoy food without discomfort

5. Your Health Journey So Far

Have you worked with other practitioners for this issue? If so, what was your experience? *

What do you feel needs to happen for you to get better? *

Check any that apply in the last 6-months or so.

Fatigue & Energy *

I wake up feeling tired even after a full night’s sleep

I experience afternoon crashes or energy dips

I rely on caffeine or sugar to get through the day

I feel “wired but tired” at night

Digestion & Gut Health *

Frequent bloating or gas

Stomach pain after eating

Acid reflux / heartburn

Constipation / diarrhea

Hormones & Menstrual Health (If Applicable)

Irregular periods / missed cycles

Mood swings or PMS symptoms

Hot flashes or night sweats

Low libido

Brain Function & Mood *

Brain fog / difficulty concentrating

Anxiety or feeling on edge

Depression or low motivation

Memory problems

Skin & Inflammation *

Acne / eczema / rashes

Unexplained body aches or joint pain

Seasonal allergies or sinus issues

Hair thinning or excessive shedding

Other Symptoms Not Listed?

Do you follow any special diet or have food restrictions? *

Other Special diet or food restrictions:

Do you have any known food sensitivities or cravings? *

Other food sensitivities or cravings:

How many meals do you eat out per week? *

0-1

1-3

3-5

8. Lifestyle & Stress

How well are you sleeping? *

I sleep through the night & wake up rested

I wake up 1-2 times but fall back asleep

I have trouble falling asleep

I wake up multiple times & feel exhausted in the morning

What’s your stress level on a scale of 1-10? (1 = No stress, 10 = Overwhelmed) *

How does stress affect you? (Check all that apply) *

Trouble sleeping

Emotional eating or cravings

Anxiety or feeling overwhelmed

Fatigue or burnout

Do you have any of the following conditions? (Check all that apply)

Digestive Issues: *

IBS

GERD / Acid reflux

Crohn’s / Ulcerative Colitis

Celiac Disease

Hormonal & Metabolic: *

Thyroid Issues

PCOS

Diabetes

Infertility

Autoimmune / Inflammation: *

Rheumatoid Arthritis

Chronic Fatigue

Food Sensitivities

Skin Conditions (eczema, psoriasis)

Other: *

Anxiety / Depression

High Blood Pressure

Migraines

10. Investment & Readiness

Our programs are designed for those who are ready to invest in real, lasting health transformation.

Have you reviewed the pricing for our programs? *

Yes, I have reviewed pricing and understand the investment.

No, I have not reviewed pricing yet.

11. Your Health Goals

What do you hope to achieve from working with us? *

When was the last time you felt truly well? *

Did something specific trigger your health decline? *

📩 What happens next?

1️⃣ You’ll receive an email with next steps and a video with our recommendations for you.

2️⃣ In the free recorded consultation we’ll go over:

✔ The root causes of your symptoms

✔ Where past approaches may have fallen short

✔ The best next steps to start feeling better

Consent & Disclaimer

🔹 Please read and agree to the following before proceeding: *

I understand that completing this form does NOT establish a patient-physician relationship with Dr. Karolina Skrzypek or Natura Integrative & Functional Medicine.

I understand that this form is for informational purposes only and is not intended to diagnose, treat, or replace medical advice from my healthcare provider.

I understand that the information provided will be kept confidential and used solely for assessment and consultation purposes.

🔹 Do you agree to the above terms? *

Yes, I have read and agree. (Required to proceed)

Please Read Carefully:

1. Personal Information

2. Are you ready to commit to a journey of true healing?

3. What Are Your Main Health Concerns?

4. How Is This Affecting Your Life?

5. Your Health Journey So Far

6. Your Symptoms

7. Diet & Nutrition

8. Lifestyle & Stress

9. Medical History

10. Investment & Readiness

11. Your Health Goals

12. Next Steps

Consent & Disclaimer