First Name
Last Name
Phone
*
Email
*
Have you been diagnosed with any conditions?
Autoimmune condition
Thyroid disorder
Fibromyalgia
Chronic Fatigue Syndrome
POTS/Dysautonomia
Depression/Anxiety
None
Other
Have you had any imaging done?
X-rays
MRI
CT scan
Ultrasound
Other
None
How would you rate your typical sleep?
I fall asleep easily and stay asleep
I have trouble falling asleep
I wake up frequently
I wake up feeling unrefreshed
Other
Current activity level
Mostly sedentary
Light walking/stretching
Moderate exercise 1-2x/week
Regular exercise 3-5x/week
Intense daily exercise
Do you have access to your recent lab results?
Yes
No
Need to request them
Please upload here
Rate your daily stress (1-10)
Submit