Full Name
Email
*
Phone
*
Date of birth
Instagram Handle
SEVERE WEIGHT LOSS RESISTANCE ASSESSMENT
Hormonal Imbalance
Heavy Metal Issues
Consistent & Unexplained Swelling
Chronic Lyme Flares
Chronic Gut Issues
HRT Doesn’t Help
High Histamine Responses
Brain Fog
SIBO
Insulin Resistance.
Weight Loss Resistance
Anxiety
Metabolic Syndrome
Mold Issues
Tried Dieting No Result
Don’t Get Colds or Flu
Chronic Hair Shedding.
Breast implant Illness
Auto Immune Disorder
Cardio Metabolic Condition.
Rashes/Hives.
Prolonged Fatigue
Mono/EBV flairs.
CMV.
No Success w/ Drs
Which photo represent your current body composition?
*
5-9 %
10-14 %
15-19 %
20-24 %
25-29 %
30-34 %
+40 %
Do you have any current medical conditions? If so, please share how it affects you and anything I should know. Remember, to always check with your physician before making any lifestyle changes.
What does a typical day of eating look like? What is your biggest struggle? (over eating, cravings)
Are you experiencing anything that makes you believe your hormones are off? (fatigue, low sex drive, anxiousness, hair loss etc)
Tell me about your cycle. Is it regular, irregular, do you have heavy days, clotting, PPMD?
Are you on birth control? If yes please share which one and for how long
What goals are you looking to achieve in the next 6 months?
What is holding you back from reaching this goal?
Lack of consistency
No idea where to start
Afraid to try "another" protocol
Overwhelm & frustrated
Life is really busy right now
My partner isn't supportive
Hormone deficiency
Im not working with you yet 😆
Would you like to learn more about how to work with me?
Yes, but nervous
Yes I need this now!
Unsure but would love to chat
No just want your thoughts
I agree to
terms & conditions
provided by the company. By providing my phone number, I agree to receive text messages from the business.
Submit
