Pulse-Check Intake Form

Current lifestyle snapshot

Daily movement level:

Low

Moderate

High

How would you describe your nutrition right now?

Pretty dialed in

Consistent but could improve

All-or-nothing cycles

Don’t know where to start

Tell me about your digestive health

Great

Some symptoms

Significant symptoms

If applicable, check what shows up for you:

Energy & Stress

Energy Levels

Stable

High then crash

Fatigued often

Sleep quality

Great

Okay

Struggle

Stress level

Low

Manageable

High

Overwhelmed

Hormones & Cycle (if applicable)

Where do you feel most stuck? (check all that apply)

Would you like information on deeper 1:1 support or labs after your call?

Yes please

Not right now