Name *

First Name

Last Name

How would you describe your energy levels? *

Very low. I never feel rested.

I pull through but still have bad days, especially after lunch!

Overall ok but could be better

Great! No problem!

Are you regular (meaning do you go to the toilet every day for a poop)? *

I barely ever go

I go maybe 2-3x a week // I alternate between diarrhea and constipation.

I go every other day

Yes, I go every day – at least once!

How would you describe your stress levels? *

I am so stressed and wound up

High but manageable

Not particularly stressed but when I do get stressed, it hits me pretty hard

Stress does not affect me negatively. I am chilled out.

Do you feel bloated, gassy or sleepy after meals? *

All the time, especially after lunch and dinner

Very often

Sometimes, but I know what sets it off

No

Do you have strong cravings for sweet or salty foods? *

Yes! Every day throughout the day

Very often, especially when I’m stressed

Rarely.

No, not at all.

How do you sleep? *

I am a total insomniac

I have no trouble getting to sleep but then wake up in the middle of the night and can’t get back to sleep

How is your dental health? *

My mouth is full of dental work, e.g. cavities, root canals, crowns.

I have some dental work and my gums bleed every once in a while.

I have some dental work but otherwise, my gums don’t bleed and my dental visits are uneventful.

No dental work, no gum bleeding, no problems.