This questionnaire helps us understand your baseline state and tailor education and guidance during the program. It is not diagnostic and does not replace medical care.

Please answer honestly. Short answers are sufficient. Once you have completed the questionnaire you will be taken to the WEEK 1 Page! 

You can also download the 6-week reset road map here.

Please enable JavaScript in your browser to complete this form.

Basic Information

Name *

Email *

Age

Your LocationNorth AmericaEuropeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth KoreaNorth MacedoniaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Primary Reasons for Joining

What motivated you to join this 6-week reset? (Check all that apply)

• Low or unstable energy
• Digestive symptoms
• Poor or unrefreshing sleep
• Stress / burnout / nervous system dysregulation
• Brain fog / cognitive fatigue
• “Labs are normal but I don’t feel well”

Current Symptoms & Patterns

Energy stability

Selected Value: 0

Sleep quality

Selected Value: 0

Digestive comfort

Selected Value: 0

Stress tolerance

Selected Value: 0

Mental clarity

Selected Value: 0

Do your symptoms tend to be:

• Constant
• Fluctuating
• Worse with stress
• Worse with food
• Worse with poor sleep

Daily Rhythm & Lifestyle

Typical wake time00:0000:3001:0001:3002:0002:3003:0003:3004:0004:3005:0005:3006:0006:3007:0007:3008:0008:3009:0009:3010:0010:3011:0011:3012:0012:3013:0013:3014:0014:3015:0015:3016:0016:3017:0017:3018:0018:3019:0019:3020:0020:3021:0021:3022:0022:3023:0023:30

Typical bedtime00:0000:3001:0001:3002:0002:3003:0003:3004:0004:3005:0005:3006:0006:3007:0007:3008:0008:3009:0009:3010:0010:3011:0011:3012:0012:3013:0013:3014:0014:3015:0015:3016:0016:3017:0017:3018:0018:3019:0019:3020:0020:3021:0021:3022:0022:3023:0023:30

Do you eat regular meals?

• Yes, most days
• Somewhat irregular
• Very irregular

Caffeine intake

• None
• 1–2 servings/day
• >2 servings/day

Physical activity (most weeks) (copy)

• None / minimal
• Light (walking, stretching)
• Moderate
• Intense

Digestion & Food Tolerance

Common digestive symptoms (if any)

• Bloating right after eating
• Bloating about 2 hours after eating
• Reflux / heartburn
• Constipation
• Diarrhea
• Alternating
• None significant

Foods you currently avoid or limit (if any)

you you Digestion

Stress & Nervous System

How would you describe your stress load currently?

• Low
• Moderate
• High
• Chronic / ongoing

Do you feel able to relax easily?

• Yes
• Sometimes
• Rarely

Main stressors right now

Sleep

Average sleep duration (hours/night)

Selected Value: 0

Sleep quality is mostly

• Restorative
• Light / fragmented
• Difficult to fall asleep
• Early waking

Medical Context

Do you have any diagnosed medical conditions you feel are relevant?

Current medications or supplements

Expectations & Boundaries

Please agree you understand what this program is about *

• I understand this is an educational, non-diagnostic program
• I will continue working with my local healthcare providers as needed
• I am comfortable with gradual change rather than quick fixes

Final Reflection

How would you describe your body right now?

Anything else you feel would be helpful for us to know?

Closing Note

Thank you for completing this intake.

This information helps create a shared starting point and allows the program to focus on patterns, regulation, and clarity rather than symptom chasing.

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