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Supplement Support Questionnaire

Supplement Support Questionnaire

Receive personalised supplement recommendations tailored to your health goals and current needs. This questionnaire ensures that your supplements are effective, safe, and aligned with your wellness journey.

Full Name*

Age*

Phone*

Email*

Gender assigned at birth*

Height (cm)*

Weight (kg)*

What are your primary health concerns at the moment? Please select all that apply.*

General wellness

Immune support

Constant fatigue

Digestive health

Weight management

Joint and bone health

Skin, hair, and nail health

Hormonal balance

Cardiovascular health

Mental clarity and mood support

Blood sugar regulation

Other (please specify):

Please indicate which of the following symptoms you are experiencing.*

Bloating

Constipation

Loose stools

Low energy

Chronic fatigue

Muscle cramping

Anxiety

Depression

Joint pain/stiffness

Acne

Eczema

Dry Skin

Hair loss

Weight gain

Unintentional weight loss

High blood sugars

Low blood sugars

High cholesterol

High blood pressure

Severe period pains

Heavy periods

Frequent urinary tract infections

Frequent chest infections

Other (please specify):

Do you have any other health conditions in your medical history? This information is important to ensure that any supplement recommendations are safe, effective, and tailored to your specific needs.*

No

Yes (please specify):

Are you currently taking any medications or supplements?*

No

Yes (please state names, doses, regularity):

Are you interested in support for any specific areas of nutrition? (Select all that apply)*

Vitamins (e.g., vitamin D, B-complex, multivitamins)

Minerals (e.g., magnesium, zinc, minerals complex)

Omega-3 fatty acids (e.g., fish oil)

Probiotics for gut health

Adaptogens (e.g., ashwagandha, rhodiola, ginseng)

Medicinal mushrooms (reishi, lion's mane, turkey tail)

Protein supplements (e.g., whey, soy, casein, collagen)

Herbal supplements (e.g., ginger, garlic, turmeric, chamomile)

Other (please specify):

Please describe your activity levels (e.g., sedentary, moderate, active) and your daily activities: *

Please describe your stress levels (e.g., low, moderate, high) and what typically causes your stress:*

How often do you have bowel movements?*

Once a day

More than once a day

Every other day

Less than three times a week

Do you experience any difficulties with bowel movements (e.g., constipation, diarrhoea, irregularity)?*

No

Yes (please specify):

Do you have any dietary restrictions or preferences? (Vegan, Gluten free etc)*

Have you experienced any side effects or sensitivities to supplements in the past?*

No

Yes (please specify):

What are your top priorities when choosing supplements? (Rank in order of importance, 1 being most important): Cost / Quality of Ingredients / Research baked effectiveness / Ease of use / Compatibility with other supplement or medications*

Is there any additional information you would like us to consider when making supplement recommendations?*

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