Full Name

Phone *

Email *

How often do you experience nasal congestion? *

Not a problem

Mild

Moderate

Frequent / strong

s1_q1

How often do you experience brain fog? *

Not a problem

Mild

Moderate

Frequent / strong

s1_q2

How often do you experience skin irritation? *

Not a problem

Mild

Moderate

Frequent / strong

s1_q3

How often do you experience breathing tightness? *

Not a problem

Mild

Moderate

Frequent / strong

s1_q4

How often do you experience digestive discomfort? *

Not a problem

Mild

Moderate

Frequent / strong

s1_q5

How often do you experience fatigue? *

Not a problem

Mild

Moderate

Frequent / strong

s1_q6

How often do you experience sleep disruption? *

Not a problem

Mild

Moderate

Frequent / strong

s1_q7

How often are you affected by environmental triggers such as pollen, dust, or mold? *

Not a problem

Mild

Moderate

Frequent / strong

s2_q1

How often are you affected by chemical or fragrance triggers such as cleaning products or perfumes? *

Not a problem

Mild

Moderate

Frequent / strong

s2_q2

How often are you affected by lifestyle triggers such as stress, poor sleep, or diet? *

Not a problem

Mild

Moderate

Frequent / strong

s2_q3

How predictable are your reactions to triggers? *

Not a problem

Mild

Moderate

Frequent / strong

s3_q1

How consistent are your reaction patterns overall? *

Very predictable

Somewhat predictable

Often inconsistent

Random or confusing

s3_q2

How long does it typically take you to recover after an allergy flare-up? *

Less than 12 hours

About 1 day

2–3 days

4 or more days

s4_q1

Which of the following do you experience? Select all that apply.

I feel fine until I crash

Small exposures stack over time

One trigger leads to multiple symptoms

I struggle to identify root causes

I recover slower than I used to

How would you rate your morning routine for managing your symptoms? *

Strong

Moderate

Weak

s6_q1

How would you rate your midday regulation habits? *

Strong

Moderate

Weak

s6_q2

How would you rate your evening wind-down routine? *

Strong

Moderate

Weak

s6_q3

How would you rate your overall sleep quality? *

Strong

Moderate

Weak

s6_q4

Total Score 88b9