Full Name *

Email *

Phone *

What state do you currently live in?

Washington

Oregon

Neither WA nor OR

What is your age?

Under 18

18–24

25–34

35–44

45–54

55+

Prefer not to say

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What are your top 2-3 health concerns right now?

Hot flashes or night sweats

Irregular periods or cycle changes

Mood swings, anxiety, or depression

Fatigue or low energy

Weight gain or difficulty losing weight

Sleep problems

Bloating, gas, or abdominal discomfort

Constipation or diarrhea

Food sensitivities

Brain fog or memory issues

Skin problems (acne, eczema, rashes)

Other (please specify)

(Select all that apply)

Have you ever been told your hormone labs or bloodwork are “normal,” but you still don’t feel well?

Yes

Not sure

Which symptoms are most disruptive to your daily life?

Hormone-related (hot flashes, mood swings, sleep, periods, weight)

Gut-related (bloating, constipation, diarrhea, food reactions)

Both equally

Not sure

Have you ever had advanced hormone or gut testing before (DUTCH, GI-MAP, etc.)?

Yes, hormone testing

Yes, gut testing

No, neither

Not sure

What is your main goal with this program?

Understand and balance my hormones

Fix digestive issues and improve gut health

Get a complete picture of both

Not sure, I just want to feel better