1. Your top symptoms

(Choose the ones that feel most true right now.)

Fatigue / low energy Bloating or digestive issues Weight gain or difficulty losing weight Brain fog or trouble focusing Trouble falling or staying asleep PMS, cycle changes, or perimenopause symptoms Joint pain, body aches, or chronic inflammation

2. How long has this been going on?

Less than 3 months 3–12 months More than 12 months

3. Gut & digestion

Think about your typical week.

How often do you experience bloating?

Rarely / almost never A few times a week Most days

Your bowel movements are:

Regular and easy to pass Sometimes loose or sometimes hard Frequently loose, constipated, or alternating

4. Adrenals & stress hormones

Do you feel “tired but wired” at night?

Rarely / never Sometimes Often or most nights

Do you notice an afternoon energy crash (2–4 pm)?

No Occasionally Most days

5. Thyroid

Do you tend to feel cold (hands, feet, or overall)?

No, not really Sometimes Often or most of the time

Have you noticed changes in hair or outer eyebrows thinning?

Not really Mild Significant

6. Blood sugar & metabolism

Do you experience strong sugar or carb cravings?

Rarely Sometimes Often

Do you tend to carry extra weight around your midsection?

No Mild Yes, clearly

7. Hormones

If you menstruate: PMS, mood swings, or painful/heavy periods?

Not applicable / minimal Noticeable but manageable Significant or disruptive

Changes in libido or peri/menopause symptoms?

Not really Some Quite a bit

8. Immune & inflammation

Regular joint pain, stiffness, or body aches?

Rarely Sometimes Often

Do you tend to catch “every little bug” or have lingering flares?

No Occasionally Yes, frequently