Welcome to the Whole Body Hormone Solution. Let's start with your Free Hormonal Health Assessment.

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.

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

Your Details

First Name

Last Name *

Date of birth *

Email *

Phone *

Question 1:

1. How ready are you to commit to lasting transformation—not just short-term fixes?

Question 2:

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

Question 3:

What are your main health concerns?

(List your top concerns in order of priority)

3.1.1 Concern #1

3.1.2. How Severe?

3.1.3. What have you tried?

3.1.4. Did it work?

3.2.1. Concern #2

3.2.2. How Severe?

3.2.3. What have you tried?

3.2.4. Did it work?

Question 4:

4.1. How are your health concerns affecting your life?

My energy & ability to get things done

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

Question 5:

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

5.2. What do you feel needs to happen for you to get better?

Question 6:

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

6.1. 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

None

6.3. Hormones & Menstrual Health (If Applicable)

6.4. Skin & Inflammation

6.5. Do you have any other symptoms which are not listed?

Question 7:

Tell us about your Diet and Nutrition...

7.1.2. Other Special diet or food restrictions:

7.3. How many meals do you eat out per week?

0-1

1-3

3-5

Question 8:

Tell us about your lifestyle and stress levels...

8.1. 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

I sleep well

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

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

Question 9:

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

9.4. Other Conditions:

Anxiety / Depression

High Blood Pressure

Migraines

None

9.5. Do you have any other condition not listed?

Question 10:

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

10.1. Have you reviewed the pricing for our programs?

Yes, I have reviewed pricing and understand the investment.

No, I have not reviewed pricing yet.

*This is a premium investment in your long-term vitality, starting at $3,499 for Part 1, The Hormone Clarity Protocol, including advanced diagnostics and testing as well as initial visits with our team. 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.

Question 11:

Tell us a bit about your Health Goals...

11.1. What do you hope to achieve from working with us?

11.2. When was the last time you felt truly well?

11.3. Did something specific trigger your health decline?

Next Steps:

What happens next?

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

2. 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?