Wellness Tool

Are you male or female?*

Male

Female

How much weight would you need to lose to achieve your ideal weight?*

Less than 15 pounds

More than 15 pounds

Have you experienced any of the following genitourinary symptoms?*

Select all that apply.

Vaginal Atrophy

Vaginal Dryness

Painful Intercourse

Urinary Incontinence

Frequent Urination

None

Have you struggled with any of the following gastrointestinal symptoms:*

Select all that apply.

Bloating

Gas

Constipation

Diarrhea / Loose Stools

Abdominal Discomfort with Meals

None

Do you believe your chronological age (the number on your driver's license) matches your biological age (how you look/feel)?*

Yes, I look/feel my age

No, I look/feel older than my age

How many vitamins or supplements do you take on a daily basis?

None

1-4

5+

Have you ever tried to “reset” your body’s overall health through a gut or liver detox program?*

Yes

No

First Name*

Last Name*

Phone*

Email

Source

Wellness Planning Tool