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Wellness Assesment

Welcome! This assessment will help us better understand your current health, lifestyle, and goals .

Please complete this form within 24–48 of our appointment. Your answers will help us uncover underlying patterns and create more targeted recommendations to support your wellness journey.

🧬 It only takes about 10 minutes to complete.
We appreciate your honesty and thoughtful responses!

Click the button below to start.

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Question 1 of 22

Your name

Current Health & Wellness

First, lets start with your general overall wellness! 

Question 3 of 22

What are your top 3 health concerns right now?

Question 4 of 22

Are you currently working with a doctor or health practitioner? If yes, please specify.

Question 5 of 22

Are you currently taking any daily medications? If so, what are you taking? 

Question 6 of 22

Are you currently taking any supplements? If so, what for, what supplements and which brands. Feel free to send a picture via email after this assessment if easier. Just put "send a picture" in the question section!

Question 7 of 22

Have you been diagnosed with any chronic health conditions? (e.g., thyroid issues, PCOS, autoimmune, etc.)

Question 8 of 22

Do you experience frequent fatigue, brain fog, or mood swings?

Question 9 of 22

Do you have regular bowel movements (1-3x/day)?

Question 10 of 22

Do you experience bloating, constipation, or diarrhea?

Question 11 of 22

Have you done any detox or gut protocols in the past 6 months? (Please describe briefly)

Question 12 of 22

Do you have a gallbladder? (Yes/No)

Question 13 of 22

Have you ever taken antibiotics for a long period of time? If so, when?

Question 14 of 22

On average, how many hours of sleep do you get per night?

Question 15 of 22

Do you consume caffeine daily? (Yes/No – if yes, how much?)

Question 16 of 22

What does a normal daily diet look like for you? 

Question 17 of 22

Are you exposed to high stress levels daily?

Question 18 of 22

Do you use synthetic fragrances, perfumes, or air fresheners regularly?

Goals & Expectations

I want to learn more about what your goals are, and what optimal health means to you. 

Question 20 of 22

What would success look like for you after doing a hair scan and wellness plan?

Question 21 of 22

Are you interested in lifestyle, nutrition, and supplement recommendations based on your results?

Question 22 of 22

Outside of the knowledge from the hair scan, how can I best support you in this journey?

Confirm and Submit