START YOUR FREE METABOLIC ASSESSMENT
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Name
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Email
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Phone
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Age
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Height
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Privacy Policy
Goal Review
What is your primary fitness/weight loss goal?
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What diets or programs have you tried in the past?
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Current Weight
Goal Weight
Have you been diagnosed with any of the following? Check all that apply.
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High blood pressure
Type 1 diabetes
Type 2 diabetes
Prediabetes
Gestational diabetes
Insulin resistance
Metabolic syndrome
Overweight or obesity
PCOS / PMOS
Fatty liver (NAFLD / MAFLD)
Reactive hypoglycemia
Digestive issues (GERD, IBS, reflux, etc.)
Thyroid disorder
Other
None of the above
Which of the following do you experience on a regular basis (daily or several times per week)? Check all that apply.
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Brain fog / difficulty concentrating
Cravings / food noise
Struggle going more than 2–3 hours without eating
Difficulty falling / staying asleep
Energy crashes / fatigue
Feeling wiped out during or after exercise
Headaches
High or chronic stress
Shift work or irregular sleep schedule
None of the above
Other
Have you ever experienced symptoms of low blood sugar after eating (e.g., feeling shaky, sweaty, anxious, or ravenous 1–3 hours after a meal)?
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Skin & body changes. Check all that apply.
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Acne
Darkened or thickened skin (neck, armpits, knuckles, etc.)
Skin tags
Joint pain or stiffness
Weight gain, all over
Weight gain, specifically around the abdomen
None of the above
How would you rate your food quality?
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How would you rate your daily energy levels?
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Do you consume large amounts of coffee or energy drinks to get through the day?
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How would you rate your daily stress levels?
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How do you cope with stress (ex. exercise, food, meditation, reading, watching TV, scrolling social media, etc.)?
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On average, how many hours of sleep do you get per night?
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How would you rate the quality of your sleep?
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How active are you?
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This assessment is not about coaching but are you interested in hearing more about 1:1 coaching?
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By providing us with your information you are consenting to the collection and use of your information in accordance with our Privacy Policy.
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