Full Name *

Phone *

Email *

Gender -  *

Male

Female

Have you experience in the past 4 weeks? (check all that apply)-L T *

Tired (even after 8 hours of sleep)

Cold hands, feet, or nose

Hair thinning (especially outer eyebrows)

Dry, flaky skin

Constipation or sluggish digestion

Brain fog or trouble focusing

Weight gain despite no change in diet

Puffy face or body

Hoarse voice

Low mood or mild depression

Irregular or heavy periods

Low libido

Have you experience in the past 4 weeks - (check all that apply) - HT *

Rapid heartbeat or heart palpitations

Anxiety or feeling wired

Heat intolerance or hot flashes

Diarrhea or loose stools

Insomnia

Hand tremors

Muscle weakness

Sweating more than normal

Thinning hair

Light or irregular periods

Have you experience in the past 4 weeks? (check all that apply) - LE  *

Hot flashes or night sweats

Vaginal dryness or pain with sex

Trouble sleeping (especially second half of cycle)

Low sex drive

Dry skin or dull complexion

Depression or mood dips

Brain fog

Bone or joint aches

Irregular or absent periods

Have you experience in the past 4 weeks? (check all that apply) - EE *

Heavy, painful, or clotty periods

Breast tenderness or swelling

PMS with mood swings or bloating

Weight gain (especially hips/thighs)

Water retention

Fibroids, endometriosis, or ovarian cysts

Anxiety or irritability

Trouble falling or staying asleep

Headaches (especially before period)

Have you experience in the past 4 weeks? (check all that apply)- LP *

Spotting before your period starts

Short luteal phase (under 10 days post-ovulation)

Trouble staying pregnant or history of miscarriage

PMS: mood swings, anxiety, weepiness

Insomnia before your period

Feeling tense, edgy, or overwhelmed

Irregular periods

Bloating and fluid retention

Have you experience in the past 4 weeks? (check all that apply) - IR *

Belly fat that won’t budge

Intense carb or sugar cravings

Energy crashes after meals

Acne (especially jawline/chin)

Irregular or absent periods

Dark skin patches (neck, armpits)

Skin tags

Fatigue after eating

Family history of diabetes

Bloodwork shows high insulin or glucose

Have you experience in the past the past 4 weeks? (check all that apply) - HC *

Wired but tired at night

Belly fat or puffy face

Trouble sleeping or staying asleep

Cravings for salt or sugar

Anxiety, racing mind, or feeling “on edge”

Skin breakouts or cystic acne

Hair thinning or shedding

Trouble recovering from workouts

High blood pressure

Have you experience in the past 4 weeks? (check all that apply) - LC *

Wake up tired despite sleeping all night

2–4pm energy crash

Need coffee to function

Feel dizzy or lightheaded when standing

Low blood pressure

Poor stress tolerance

Crave salty foods

Frequent colds or illness

Easily overwhelmed

No drive or motivation

Have you experience in the past 4 weeks? (check all that apply) - pcos *

Irregular or missing periods

Acne on jaw, chin, or back

Thinning hair on scalp but hair growth on chin/lip

Weight gain (especially belly)

Oily skin

Trouble getting pregnant

Blood sugar issues

Diagnosed with “polycystic ovaries” on ultrasound

Mood swings or anxiety

Cravings for carbs/sugar

Have you experience in the past 4 weeks? (check all that apply) - HA *

Hormonal acne

Hair loss or thinning at crown

Facial hair (chin/lip)

Oily skin or scalp

Muscle gain without trying

Deepening voice

Aggression or irritability

Irregular periods

Have you experience in the past 4 weeks?-( check all that apply) - LT *

No motivation to train or compete

Decreased sex drive

Muscle loss or poor muscle tone

Depression, apathy, or flat mood

Poor strength gains in the gym

Fat gain despite tracking

Low energy

No desire or “drive”

Have you experience in the past 4 weeks? (check all that apply) - EMD *

Strong PMS symptoms

Breast tenderness or fibrocystic breasts

Headaches around your period

History of estrogen-sensitive conditions (fibroids, endo, breast cancer)

You’ve had reactions to birth control

Bloating and fatigue before your period

You don’t feel better even after lowering estrogen foods

Have you experience in the past 4 weeks? (check all that apply) - LR *

You're never full — always hungry

Cravings after meals

Plateaued despite tracking calories

You have to starve yourself to lose weight

Trouble sleeping or waking frequently

Overweight despite “clean” eating

High body fat but low energy

Struggle with yo-yo dieting

Have you experience in the past 4 weeks? (check all that apply) - GD *

You’re hungry again 1–2 hours after eating

Hard to fast — get shaky, weak, hungry

Nighttime hunger or snacking

Eating more doesn’t satisfy

Constantly thinking about food

Crave sweets or snacks even when full

Have you experience in the past 4 weeks? (check all that apply) - LD *

Low motivation / difficulty initiating tasks

Brain fog or poor concentration

Low drive to exercise or be productive

Reduced pleasure from things that used to feel rewarding

Increased cravings for sugar, caffeine, or stimulants

Fatigue despite adequate sleep

Mood swings or feeling emotionally flat

Procrastination or difficulty finishing tasks

Low libido

Poor stress tolerance / feeling overwhelmed easily

Have you experience in the past 4 weeks? (check all that apply) -I *

Fatigue or constant low energy

Shortness of breath with mild activity

Pale skin or pale inner eyelids

Cold hands and feet

Frequent headaches or dizziness

Hair thinning or increased hair shedding

Brittle nails or spoon-shaped nails

Craving ice or non-food items (pica)

Restless legs, especially at night

Rapid heartbeat or heart palpitations

Have you experience in the past 4 weeks? (check all that apply) - D *

Frequent illness

Low mood, especially in winter

Joint or muscle pain

Fat loss resistance

Always tired

Have you experience in the past 4 weeks? (check all that apply) - M *

Trouble falling or staying asleep

PMS cramps

Muscle twitches or cramps

Anxiety or restlessness

Constipation

Have you experience in the past 4 weeks? (check all that apply) - BV *

Tingling in hands or feet

Fatigue and brain fog

Hormonal mood swings

Mouth sores or cracked lips

Poor stress response

Have you experience in the past 4 weeks? (check all that apply) - Z  *

Hormonal acne

Poor immune system

Loss of taste or smell

White spots on nails

Hair shedding

Have you experience in the past 4 weeks? (check all that apply) - I *

Sluggish thyroid

Dry skin

Puffy face

Irregular periods

Weight gain despite effort

Any comment/feedback *

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