Personalised Supplementation Assessment personalised supplementation assessment Take the assessment below to receive a Practitioner Prescription tailored to your goals, lifestyle, and diet. Once complete, you will receive your prescription and online order form within 48 hours. π All information shared will be kept strictly confidential. Name * First Name Last Name email * Phone Number * Height * CM Weight (Optional) Do you want to see changes in your body weight or composition? If yes, please describe what changes. What are your health, lifestyle and dietary goals? * What are your current health concerns? Are you currently taking any medication or supplementation? * Please be specific and list ALL products, including brand & dosage. Are you currently trying for a baby, pregnant, or recently given birth? * Please provide further information below. Trying to conceive Pregnant Postpartum Breastfeeding None of the above Do you have any major health concerns/conditions we need to be aware of? * Is there a particular product/s you would like to order? List them here, you can then skip the following questions and scroll down to submit your form. Do you feel your current diet is healthy? Yes No If No, what do you think your current diet is lacking? What are your top three health concerns that you would like to focus on? Sleep Stress Energy Hormone Balance & PMS Menopause Acne Eczema Digestion Joint Support Depression Anxiety Weight Loss Weight Gain Thyroid Health Detoxification Wellness Further Discussion of Concerns For example, expand on particular PMS/Menopause symptoms. Do any of these digestive concerns relate to you? Bloating Constipation Diarrhea Excessive Gas Reflux/Indigestion If Yes, how often? Do you have a bowel movement every day? Yes No If no, how often? Do you currently sleep 7-9 hours per night? * Yes No Struggle to fall asleep Wake frequently Rate your average daily stress on a scale of 1 to 10 1 - low, 10- high 1 2 3 4 5 6 7 8 9 10 Rate your average daily energy on a scale of 1 to 10 1 - low, 10 high 1 2 3 4 5 6 7 Do you follow a special diet? Gluten Free Dairy Free Paleo Ketogenic Intermittent Fasting Vegetarian Pescatarian Vegan Low FODMAP Do you have any allergies? How often do you eat red meat? Never Rarely 1-2 times per week 3 or more times per week How often do you eat fish or seafood? Never Rarely 1-2 times per week 3 or more times per week How many handful of vegetables do you eat per day? None 1 to 2 3 to 4 5 or more Do you need support managing sugar cravings throughout the day? Yes No How many meals per week do you eat out? Including takeaways, cafe/restaurant, bought lunches None 1 to 2 3 to 4 5 or more How many alcoholic drinks do yo consume per week? None 0-2 3-5 5-8 8 or more Do you smoke or vape? No Yes Socially notes Please provide any further necessary information. Consent * I agree that all of the information I have provided is true and correct. This prescription is intended for my personal use and l have provided all of the information needed to ensure its safety and suitability for my individual health needs. I acknowledge that this product is not a substitute for medical advice, and I take full responsibility for its use in accordance with the recommended dosage and guidelines Agree Do not agree Thank you! Weβll be in touch within 48 hours with your prescription and order form.
