FOCUS: How would you rate your ability to focus and stay present during the day? *

🔥 Laser-focused

😐 Decent, but could be better

😵‍💫 All over the place most days

MOOD: How’s your overall mood lately? *

😊 Generally happy and even-keeled

😕 A little up and down

😩 Easily overwhelmed, anxious, or low

STRESS LEVELS: How would you describe your stress levels right now? *

😎 Pretty chill

😬 Manageable but noticeable

😱 Stress is high and taking a toll

HORMONES: How would you describe your energy + mood across the month? *

🌸 Steady and balanced most of the time

🌊 A little up and down with my cycle or stress levels

🌪 Big swings. Fatigue, mood shifts, or PMS really affect me

SLEEP: How well are you sleeping? *

💤 Fall asleep easily, sleep through the night

😴 Takes me a while to unwind

😩 Wake up tired or frequently during the night

DIGESTION: How’s your digestion on a regular basis? *

💩 Totally regular and healthy

😬 Occasional bloating or discomfort

🚨 Frequent digestive issues or irregularity

HAIR + SCALP HEALTH: How would you describe your hair and scalp lately? *

💁‍♀️ Healthy, strong, no concerns

🧴 A little dry, oily, or flaky

🧠 Thin, dull, or breaking more than usual

SKIN HEALTH: How’s your skin doing lately? *

✨ Clear and glowing

🤷‍♀️ Some breakouts or dullness

🆘 Dry, irritated, or inflamed

KIDS: Do you have kids at home? *

👨‍👩‍👧‍👦 Yes

🚫 No

Name *

First Name

Last Name