How would you describe your stress levels most days? *

Very relaxed and peaceful

Generally calm with occasional stress

Manageable but always busy

Constantly overwhelmed and anxious

How often do you have trouble falling asleep or staying asleep? *

Rarely or never

1-2 times per week

3-4 times per week

Almost every night

How often do you feel "wired but tired"? *

Never

Occasionally

Several times a week

Daily

Do you feel like you're constantly in go-go-go mode? *

No, I have good work-life balance

Sometimes

Most of the time

Yes, I can never slow down

How do you handle unexpected changes or challenges? *

I roll with it easily

I adapt pretty well

I get stressed but manage

I feel completely overwhelmed

How often do you feel anxious or worried? *

Rarely

Sometimes, during stressful periods

Often, even about small things

Constantly, my mind races

How often do you experience energy crashes in the afternoon? *

Rarely or never

A few times a week

Most days

Every single day

Do you get "hangry" if you skip meals? *

No, I feel fine skipping meals

Slightly irritated but manageable

Yes, I feel cranky and unfocused

Extremely hangry - mood swings, irritability

How often do you crave sweets or carbs? *

Rarely have strong cravings

Occasionally, usually around my period

Strong cravings daily, especially afternoon/evening

Constantly throughout the day

Do you feel tired after eating meals? *

No, I feel energized after meals

Sometimes, depending on what I eat

Often feel sluggish after eating

Yes, I need a nap after most meals

How stable is your mood throughout the day? *

Very stable, rarely have mood swings

Pretty stable with minor fluctuations

Noticeable ups and downs

Major mood swings, especially when hungry

How often do you feel shaky, jittery, or lightheaded between meals? *

Never, I feel steady between meals

Occasionally, if I go too long without eating

Often, especially in the afternoon

Frequently, even just a few hours after eating

How often do you experience bloating? *

Rarely or never

Occasionally, usually around my period

Several times a week

Daily, especially after meals

How would you describe your bowel movements? *

Daily, well-formed, easy to pass

Pretty regular but not always well-formed

Inconsistent - sometimes constipated, sometimes loose

Constipated - less than every other day

Do you need coffee to have a bowel movement? *

No, I go regularly without coffee

Sometimes coffee triggers a bowel movement

Coffee definitely helps

Yes, I can't go without coffee

How often do you experience gas or digestive discomfort? *

Rarely

Occasionally

Several times a week

Daily, it's really uncomfortable

Do you have known food sensitivities or reactions? *

No known food sensitivities

Maybe one or two foods

A few foods I know I react to

Yes, many foods seem to bother me

How do you feel after eating certain foods? *

Great, no issues with any foods

Occasional mild discomfort

Some foods definitely don't agree with me

Many foods make me feel terrible

Do you crave salty foods? *

Rarely crave salty foods

Occasionally crave salt

Often want salty snacks

Constantly craving salt

Do you experience muscle cramps, twitches, or restless legs? *

Rarely or never

Occasionally - maybe once a month

Sometimes - a few times a month

Frequently - several times a week

How's your energy level regardless of how much sleep you get? *

High, consistent energy

Pretty good energy most days

Low energy most days

Always exhausted no matter what

Do you feel thirsty despite drinking plenty of water? *

Rarely feel overly thirsty

Sometimes feel thirsty

Often feel thirsty

Always thirsty, never feel hydrated

How often do you wake up to urinate at night? *

Rarely or never

Occasionally

Most nights

Multiple times every night

How do you feel when you stand up quickly? *

Fine, no issues

Occasionally feel slightly dizzy

Often feel lightheaded or dizzy

Always feel dizzy or see spots

How much natural sunlight do you get daily? *

Plenty of natural light exposure

Moderate amount most days

Some, but not consistently

Very little - mostly indoors

How would you rate your sleep quality? *

Excellent - deep, restorative sleep

Good - usually sleep well

Fair - some good nights, some bad

Poor - restless, unrefreshing sleep

Do you have irregular or missing periods? *

Very regular and predictable

Mostly regular with occasional variation

Somewhat irregular - varies by weeks

Very irregular or missing for months

How often do you do intense exercise? *

Rarely or light exercise only

1-2 times per week

3-4 times per week

Daily or multiple times daily

How consistent is your daily routine? *

Very consistent schedule

Pretty consistent with some flexibility

Somewhat inconsistent due to work/life

Very inconsistent, always changing

How much are you exposed to chemicals/toxins in your daily life?

Minimal - I use clean products and eat organic

Some exposure but I try to minimize

Moderate exposure from products/environment

High exposure - conventional products, polluted environment

Full Name *

Email *

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