Thank you for scheduling your appointment with Jacqui. Please take a minute and complete the questionnaire.

Full Name

Phone *

Email *

Date of birth

Gender

Female

Male

Reason for Consultation

Do you experience any of the following? (check all that apply)

Difficulty shedding weight

Belly fat and bloat

Low energy

Poor Sleep

Menopausal symptoms (hot flashes, mood swings, insomnia, brain fog)

Digestive issues (gas, constipation, loose stools, acid reflux)

Skin Conditions (rosacea, eczema, psoriasis, acne)

Hair loss

Cold hands and feet

Headaches

Food reactions

Food cravings

Wellness Goals

Briefly describe your current diet.

Your daily stress level is:

Low

Moderate

High

Very high

Are you interested in any of the following?

Blood Chemistry Analysis

Food Sensitivity Testing

Gut Health Testing

Hormonal Testing

Adrenal Stress Testing

How did you hear about Jacqui?