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Food + Mood Review

Thank you for filling out this form! The form must be submitted 48 hours prior to your session so the team has time to review it. If the form is not in prior to 48 hours before your session, you may be asked to reschedule. 

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Question 1 of 10

How old are you?

Question 2 of 10

Tell me about your daily and weekly activity level? (walks, HIIT, etc) 

Question 3 of 10

Are you pregnant, breastfeeding or planning to become pregnant? 

Question 4 of 10

Please tell me about any digestive symptoms you have - diarrhea, bloating, gas, burping etc 

Question 5 of 10

Tell me about your daily stress level from 1-10, 10 being unbearable. 

Question 6 of 10

What are your goals for your health? If you could wave a magic wand, what would your health look like in 6 months? 

Question 7 of 10

Please list out a NORMAL 3-5 days of eating for you. Please list the times of meals and snacks as well as how you felt BEFORE and AFTER that meal/snack. 

For example: 
Monday, breakfast, 8 AM

2 slices of toast peanut butter 

Before: felt very hungry 

After: still hungry but in a hurry

 

Snack, 3 PM 

coffee with milk and a cookie

before: very hungry

after: kind of sleepy 

 

Question 8 of 10

What are your goals for our time together? 

Question 9 of 10

Anything else you would like Alex to know? 

Question 10 of 10

Are you interested in having your mineral levels tested? 

A

No, thanks!

B

I would love to hear more.

C

Yes, please!

Confirm and Submit