This questionnaire helps Jason and Nick's frameworks give you personalised, accurate answers. It's saved to your account and used in every consultation. You can update it anytime from Settings.
KIDS — NAMES & AGES
Age of kids helps understand how recent pregnancies / births were and the hormonal timeline since each delivery.
ALLERGIES
Include food, environmental, and seasonal allergies. Histamine-driven reactions — high body heat, flushing, itchiness, gut upset, heart palpitations, anxiety — should be noted here as they indicate a histamine intolerance pattern.
HOT FLASHES / TEMPERATURE CHANGES / ITCHINESS / RED FACE / HEART PALPITATIONS / ANXIETY
CURRENT PRESCRIPTIONS
SUPPLEMENTS
List everything you currently take — name, dose, and timing if known. Include vitamins, minerals, herbs, protein powders, greens, adaptogens, and anything else. More detail = more accurate analysis.
PAST OR CURRENT DIAGNOSES
LAST BLOOD WORK — APPROXIMATE DATE & WHAT WAS TESTED
WORKING WITH A DOCTOR OR PRACTITIONER?
Select…
Yes — conventional MD
Yes — functional practitioner
Yes — both
No
FERTILITY STRUGGLES?
Select…
Yes — currently trying
Yes — past struggles
No
Not applicable
PERIOD HISTORY
CURRENT GUT SYMPTOMS OR CONCERNS
BOWEL MOVEMENTS — FREQUENCY, CONSISTENCY, TIMING
GUT-RELATED MEDICATIONS OR SUPPLEMENTS
❤️ Hormonal Health & Libido
IS SEX DRIVE PRESENT?
Select…
Yes — normal
Yes — but lower than before
Minimal
Absent
NOTABLE HORMONAL CHANGES OR CONCERNS
DIFFICULTY FALLING ASLEEP?
Select…
No — out within minutes
Sometimes — 20–30 min
Yes — often takes over 30 min
Yes — severe, takes hours
DIFFICULTY STAYING ASLEEP?
Select…
No — sleep through the night
Sometimes wake once
Yes — wake multiple times
Yes — severe disruption
ENERGY LEVELS — DESCRIBE YOUR TYPICAL DAY
Cancer Client — Additional Information
CANCER TYPE & SUBTYPE
FULL MEDICATION LIST
CURRENT SUPPLEMENT LIST
LATEST CBC / CMP — KEY VALUES
WEIGHT TREND
Select…
Stable
Gaining weight
Losing weight — intentional
Losing weight — unintentional
CURRENT SYMPTOMS
ONCOLOGY TEAM INFO
RESTRICTIONS FROM ONCOLOGY TEAM
GOALS — WHAT DO YOU WANT TO ACHIEVE WITH FUNCTIONAL SUPPORT?
