Gut, Liver and Cell Toxicity

Assessment Form

Thank you so very much for investing the next few minutes in you. :-) The more thoughtful your answers, the more clarity we will have together.

Today's Date: *

Office Use Only

First Name *

Last Name *

Phone *

Email *

Address *

City *

State *

Postal code *

Gender *

Male

Female

Other

Age *

Whom or what (TV, online, etc.) may we thank for referring you? *

TV

Facebook

Instagram

TikTok

Google Search

Referral

Other

Referral from a friend?

Ideal Weight *

Current Weight *

My current health goals are ... *

Current Rx Medicine (brand not critical, just what it's for) *

On a scale of 1 to 10 how committed are you to hitting your goal? *

What is your energy level on a scale of 1 to 10? *

Is your family excited about you becoming healthy and/ or losing weight? *

Yes

No

Do you have less motivation / zest for life? *

Yes

No

Do you suffer from brain fog or memory issues lately? *

Yes

No

Mood swings? Irritable or easily angered? *

Yes

No

Digestion / Gut and Liver Assessment

Do you experience? Choose any that apply. *

Bloating

Reflux

Constipation

Diarrhea

Indigestion

None of the above

Which foods make any of the symptoms worse?

Do you crave carbs- sugar, beer, wine or bread etc? *

Yes

No

Ever had candida or yeast issues? *

Yes

No

Do you sleep well? *

Yes

No

Ever take antibiotics? *

Yes

No

Do you suffer from inflammation? (aches and pains, stiff joints, trouble concentrating, etc.) *

Yes

No

Stress Assessment / Adrenal Function

Do you have a close support network/family? *

Yes

No

Are you happy with current profession? *

Yes

No

Are you comfortable financially? *

Yes

No

Are you satisfied with your life's direction? *

Yes

No

Are you frequently anxious, depressed, or have panic attacks? *

Yes

No

Do you recover less easily from exercise? (worn out for a day or two) *

Yes

No

Just curious, which is the most important for you? *

EFFECTIVENESS "My results are my top priority."

TIME "I want my results quickly."

SERVICE "I will need extra support along the way."

AFFORDABILITY "Cost is a major concern."