Gut Health Done Right Intake Form

Name*
First Last
Email*
Phone*
We will protect your data in accordance with our privacy policy

When is your birthday? DOB*
Occupation?*
Height?*
What is your weight? Would you like your weight to be different?*
How much sleep do you get each night on average?*
Do you sleep well at night?*
How often do you eliminate your bowels?*

List any medications you are now taking & what they are for.*
List any nutritional supplements you are now taking.*
Please list any health concerns you would like changed.*

You can only select one answer. Answer to the best of your ability based on your current health concerns. During your consultations we can discuss any other issues and whether or not you have inflammation caused by issuies in your gut.
I have spent an extended amount of time:*
- Exposed to toxins (amalgam fillings, mold etc.)
- On an antibiotic or birth control pills
- Cravings processed foods and sugary desserts
- Addicted to caffeine drinks or coffee
- Taking a pill or acid reflux or bloating
- I don't relate to any of these

When it comes to my family, job & relationships:*
- I am a "worry wart" & I seem to say "yes" to everyone
- I often feel insecure, lack of confidence and grief
- My schedule is very stressful and demanding causing strain on my relationships
- I am driven to achieve but often focus too much on myself rather than others
- I don't relate to any of these

I'm embarrased that I have issues with:*
- Fungal issues (toe fungus, yeast infections, etc.)
- Thinning hair or hair loss, decreased libido
- Skin issues (eczema, psoriasis)
- Burping & gas
- Constipation
- I don't relate to any of these

In conflict, this best describes me & my emotions:*
- I often overreact and get into dramatic fights b/c of my emotions
- Perfectionist tendencies, commitment to doing what I believe is "right"
- Anxiety & Depression have been constant struggles
- Exhausted from analyzing every aspect of a situation & get caught up on empathy for others
- Store unforgiveness
- I don't relate to any of these

I have seen the doctor with concern about my:*
- Colon or Lungs
- Spleen or intestinal issues
- Gallbladder, gallstones or liver
- Heart (high blood pressure or heart disease)
- Adrenals, Thyroid or Kidneys
- I don't relate to any of these

My main reason for looking into this gut challenge relates to my issues with:*
- Food sensitivities to things such as wheat, milk and eggs
- Hormonal imbalance such as thyroid or adrenal issues such as adrenal fatigue
- Acid reflux & digestion issues
- Gallstones, gallbladder issues or have had my gallbladder removed
- Bloating, diarrhea and yeast infections
- I don't relate to any of these

My food/snack weakness is:*
- COFFEE, COFFEE, COFFEE
- Ice cream
- Pasta & Cookies
- Meat & high fat foods
- French fries and burgers
- I don't relate to any of these

My main health issues and concerns include:*
- Autoimmune disease (Chrohns, IBS, etc.)
- Frequent yeast infections or white coating on my tongue
- Gallbladder & liver issues
- Hypothyroidism, sluggish thyroid or adrenal fatigue
- Acid reflux & SIBO
- I don't relate to any of these

What emotions or life events have you experienced the most in the last year?*
- Negative emotions
- Depression
- Deep grief or trauma
- Loss of love or great disappointment in a relationshop
- Held a grudge; struggle to forgive
- I don't relate to any of these

What are the biggest emotions you experience when something doesn't go your way or you face adversity?*
- Frustration & Anger
- Worry & Anxiety
- Overreact or heightened emotional response
- Upset, depressed
- Overwhelmed, stressed, exhausted
- I don't relate to any of these

When it comes to eating, I tend to:*
- Consume high amounts of sugary foods and caffeine weekly
- Crave high-sugar foods and refined grains
- Consume cold foods and drinks like salad, smoothies and ice water
- Devour food, both eating too quickly and eating too much
- Consume lots of hydrogenated fats (fried foods, store-bought cookies, etc.) and simple carbohydrates (break, pasta, candy, etc.)
- I don't relate to any of these.

Most days I struggle with:*
- Morning fatigue/trouble waking up
- Brain fog (lack of focus & difficulty staying on task)
- Inflammation & allergies
- Overeating or needing an antacid
- Temptation of high fat foods
- I don't relate to any of these

More than once a week I experience:*
- Indigestion or acid reflux
- Digestive issues such as diarrhea or constipaton
- Exhaustion, even when I get enough sleep
- White coating on my tongue after consuming carbohydrates
- Skin issues such as dry skin, acne, eczema or psoriasis
- I don't relate to any of these

I currently am struggling most with:*
- White coating on my tongue after meals
- Bloating & Gas after meals
- Chronic Issues (Lupus, Hashimotos, Rheumatoid Arthritis, Lupus, etc.)
- Digesting Fats & Gallbladder issues
- Fatigue & Weight Gain
- I don't relate to any of these

Eating often looks like or includes:*
- Cold Foods (ice water, cold smoothies or frozen treats)
- Food "on the go" (I often eat quickly and may overeat)
- High fat & processed foods
- Coffee & caffeine
- Food sensitivities (gluten, dairy, etc.)
- I don't relate to any of these

Do you have thyroid issues or sluggish metabolism?*
- Yes
- No
Do you have low energy or frequent fatigue?*
- Yes
- No
Do you have frequent diarrhea or loose stools?*
- Yes
- No
Do you have gas, bloating, or any other digestive issues one or more per week?*
- Yes
- No

Do you have skin conditions like rosacea, eczema, acne, or rashes?*
- Yes
- No
Do you struggle with depression, anxiety, or lack of focus?*
- Yes
- No
Have you ever struggled with any type of candida, yeast, or fungal issues, or do you have a white coating on your tongue?*
- Yes
- No
Have you been diagnosed with ulceration colitis, Crohn's disease, or IBS?*
- Yes
- No

Do you suffer from any type of pain, including joint pain or headaches?*
- Yes
- No
Do you have an autommune disease like Hashimoto's thyroiditis, psoriasis, or multiple sclerosis?*
- Yes
- No

Consent*
I agree to the privacy policy.
FUNCTIONAL WELLNESS HEALTH CONSULTATION

Our services neither diagnose nor prescribe for disease conditions. All clients are encouraged to seek competent medical help when those services are deemed necessary. The client accepts total responsibility for his/her own health care and maintenance.

Nothing said, done, performed, typed, printed or produced by us is intended or meant to diagnose, prescribe, treat a disease or take the place of a licensed physician. Our program (which includes several services) involves Lifestyle Analysis, elimination of harmful lifestyles and habits, and the cultivation of positive mental attitudes. The modalities are designed solely to enhance physical fitness, mental attitude and alertness, and good nutrition.

We do not diagnose or make any attempt to cure any disease condition, and we make no claims or imply any claims that suggestions given to the client are to cure any condition. Furthermore, we do not claim that any supplemental material we may suggest will cure any condition or that its purpose is to treat any condition. In essence, we do not prescribe for or treat any disease.

Nutritional research assessments and suggestions are intended only for the support and maintenance of optimal health and do not involve diagnosing or prescribing food supplements or remedies for the treatment of disease conditions.

Fit and Fabulous with Tiffany, LLC is committed to the highest level of integrity in all our dealing with our clients. We will take appropriate actions and safeguards to protect your personal information.

Refund Policy

There are no refunds on services that include one on one time or coaching groups. Contracts can not be canceled for one on one services, and no refunds will be granted. All Solle Naturals products have a 30 day satisfaction guarantee. That refund must be processed directly through Solle Naturals to recieve your refund.

I have read all of the above and understand and agree with it completely. I therefore consent to participation with Tiffany DeLuisi in a program within the framework stated above
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Gut Health Done Right Intake Form

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