Full Name
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Email
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Phone
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Date of birth
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Instagram Handle
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Please check off any/all symptoms you're experiencing:
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Headaches
Dizziness
Consistent & Unexplained Swelling
Insomnia
Chronic Gut Issues
Heartburn
High Histamine Responses
Brain Fog
SIBO
Insulin Resistance.
Weight Loss Resistance
Anxiety
Muscle Weakness
Craving Sweets
Tried Dieting No Result
Low Libido
Chronic Hair Shedding
Breast implant Illness
Auto Immune Disorder
Binge Eating
Rashes/Hives
Prolonged Fatigue
Compulsive Eating
Acne
No Success w/ Drs
Mood Swings
PMDD
PCOS
Which photo represent your current body composition?
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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
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