Discovery Call with TM Wellness

Section 1: Basic Health Profile

Full Name

Email *

Phone *

Age & Height: *

Current Weight & Your Goal Weight:

Primary reason for seeking support: *

Section 2: Medical Background

Current Medications: *

Current Supplements: *

Section 3: Digestive & Gut Health

How often do you have bowel movements? *

3+ a day

1-2 per day

Every other day

Less than 3 per week

Have you ever done/completed a parasite cleanse or gut protocol? *

Yes

No

History of antibiotic use: *

Rare

Occasional

Frequent

Section 4: Food Sensitivities & Diet Patterns

Have you been tested for food sensitivities? *

Yes

No

If yes, list results. *

How many meals per day do you typically eat? *

1-2

3

4-5

6+

How often do you consume - Ultra-processed Foods & Alcohol *

Rare

Occasionally

Weekly

Daily

Section 5: Blood Sugar & Energy Patterns

Energy levels throughout the day *

Do you rely on caffeine for energy? *

Yes

No

If yes, how many cups per day? *

Section 6: Hormone Health

Women’s Hormone Health

Age of first menstration:

Are your cycles regular?

Yes

No

In Menopause

Cycle length?

Have you used hormonal birth control?

Yes

No

If yes, why type and for how long?

Men's Hormone Health

Have you had your testosterone levels tested?

Yes

No

Section 7: Sleep & Recovery

How many hours of rest do you get each night? (average) *

What is your Sleep quality? Rate 1-10 *

Do any of these sound like you? *

Difficulty falling asleep

Waking during the night

Early morning waking

Feeling unrefreshed

Do you take any of these? *

Section 8: Stress & Cortisol Patterns

What is current state of stress? Rate 1-10 *

Do you feel any of these below: *

Wired but tired

Burned out

Anxious

Chronically overwhelmed

Section 9: Exercise & Movement

Current training frequency: *

How would you rate your recovery? *

Poor

Moderate

Good

Section 10: Body Composition & Metabolism

Where do you primarily store body fat? *

Abdomen

Hips/Thighs

Arms

Even all over

Do you feel your metabolism is: *

Slow

Average

Fast

Have you had weight gain despite dieting? You Plateau despite exercise or have muscle loss? *

Section 11: Lifestyle & Environment

What is your current water intake? Please comment in ounces. *

Do you filter your water? *

Yes

No

Do you cook most of your meals at home? *

Yes

No

Have you been exposed to any of these: *

Plastics

Pesticides

Mold

Environmental toxins

Section 12: Goals & Commitment

Please list your Top 3 Health goals *

What has prevented you from achieving these goals previously? *

How committed are you to making a lifestyle change? Rate 1-10 *

Section 13: Coaching Expectations

What do you expect from working with an NP (nutrition practitioner)? *

What level of accountability helps you succeed? *

Section 14: Final Assessment Question

Is there anything about your health history, lifestyle, or concerns that you feel are important for me to know before creating your personal protocol? *

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