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Contact Details

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Employment Information

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Gastrointestinal Health Questionnaire

STEP 1 : STOMACH HEALTH

Please indicate to what level you experience indigestion or food comes back up into your esophagus/ throat rafter you eat *

Never

Occasionally

Often

Frequently

Please indicate to what level you experience excessive burping, belching and/or bloating following meals *

Never

Occasionally

Often

Frequently

Please indicate to what level you experience a sensation that food just sits in your stomach creating uncomfortable fullness, pressure and bloating during or after a meal *

Never

Occasionally

Often

Frequently

Please indicate to what level you experience a burning sensation in the lower part of your chest, especially when lying down or bending forward *

Never

Occasionally

Often

Frequently

STEP 2 : SMALL INTESTINE AND PANCREAS HEALTH

Please indicate to what level you experience bloating around the belly button *

Never

Occasionally

Often

Frequently

How often do you recognize food particles in your stool? *

Never

Occasionally

Often

Frequently

Please indicate to what level you experience delayed digestion, fullness, or tension in your abdomen, occurring 2-4 hours after eating a meal *

Never

Occasionally

Often

Frequently

I get tired after eating a regular sized meal *

Never

Occasionally

Often

Frequently

STEP 3 : COLON OR LARGE INTESTINE HEALTH

Please indicate to what level you experience gas production with need for release *

Never

Occasionally

Often

Frequently

Please indicate to what level you experience loose bowel movements *

Never

Occasionally

Often

Frequently

I can go 24 hours without a bowel movement *

Never

Occasionally

Often

Frequently

Please indicate to what level you experience urgency/pain/cramping that is relieved by a bowel movement *

Never

Occasionally

Often

Frequently

STEP 4 : SYSTEMIC GUT HEALTH CONCERN

Do you experience athlete’s foot, thrush, or recurrent fungal infections of any kind? *

Yes

Have you ever been diagnosed with an underactive thyroid? *

Yes

Have you ever been diagnosed with an autoimmune disease (such as psoriasis, lupus, rheumatoid arthritis or similar)? *

YES

Do you suffer from fatigue? *

Yes

Do you experience low mood, depression, anxiety, or another mental health concern? *

Yes

Do you experience joint pain on a regular basis? *

Yes

Have you ever been diagnosed with Endometriosis or Poly-Cystic Ovarian Syndrome? *

Yes

Experience asthma or eczema? *

Yes

MENSTRUAL CYCLE QUESTIONNAIRE

STEP 1 : Low Progesterone Questionnaire

Please indicate to what level you experience agitation, low mood, or mood swings pre-period. *

Never

Occasionally

Often

Frequently

In your general day-to-day life, please indicate to what level you experience anxiety *

Never

Occasionally

Often

Frequently

Please indicate to what level you have sweet cravings pre and during period. *

Never

Occasionally

Often

Frequently

Please indicate to what level you experience fatigue pre and during period *

Never

Occasionally

Often

Frequently

Please indicate to what level you experience irregular bleeding *

Never

Occasionally

Often

Frequently

STEP 2 : High Estrogen Questionnaire

Please indicate to what level you experience heavy bleeding during your period. *

Never

Occasionally

Often

Frequently

When thinking about your body shape, do you predominantly store excess body fat on the hips, thighs and buttocks? (As opposed to on your stomach, arms or back). *

Never

Occasionally

Often

Frequently

Do you have difficulty losing weight even when eating a balanced, wholefood diet and regularly exercising? *

Yes

Do you experience fibrous or clotted tissue in your menstrual blood? (Please select yes if you know you have fibroids) *

Yes

Please indicate to what level you experience irritability, mood swings, tender breasts, food cravings, fatigue, or painful cramping in the lead up to your period. *

Everyday

Often

Sometimes

Never

In day-to-day life, please indicate to what level you experience migraines or headaches *

Everyday

Often

Sometimes

Never

STEP 3 : High Androgens Questionnaire

Do you experience excess hair on your face, chest (snail trail around your belly button) and/or arms? *

Yes

Do you experience acne on the back, face, chest or arms? *

Yes

Do you experience greasy skin and/or hair? *

Yes

Do you experience thinning head hair? *

Yes

In day-to-day life, please indicate to what level you experience emotional reactivity, anger and/or irritability. *

Everyday

Often

Sometimes

Never

Have you been diagnosed with ovarian cysts and/or Polycystic Ovarian Syndrome (PCOS) and/or insulin sensitivity? *

Yes

STEP 4 : Cortisol Imbalance Questionnaire

You wake up tired, even after 8 hours sleep and might need coffee to get you going. *

Everyday

Often

Sometimes

Never

You feel tired at 3pm (the 3pm slump). *

Yes

Please indicate to what level you experience a lack of hunger first thing in the morning *

Never

Sometimes

Often

Always

Please indicate to what level you experience a need to wear sunglasses, even on a cloudy day *

Never

Sometimes

Often

Always

Please indicate to what level you experience difficulty recovering from a cold or infection. *

Never

Sometimes

Often

Always

Please indicate to what level you experience salt cravings *

Never

Sometimes

Often

Always