Gut Health Healing Plan

First Name

Phone Number

1. Please list your gut health issues (Fatigue, bloating, digestion, brain fog, irritability, weight gain, lack of sleep, poor skin). Indicate all that apply and add any others that are a problem for you.

2. Are you interested in incorporating more plant based options into your diet?

Yes

I am not sure

3. How many times a week do you drink alcohol?

I don’t drink

1-2 drinks a week

3-4 drinks a week

5+ drinks per week

4. How many cups of coffee do you drink per day?

I don’t drink coffee

1-2 cups a week

2-3 cups a week

3+ cups a week

I drink something else other than coffee to get me started for the day

5. Do you currently take any supplements to help your gut?

6. Are you a person who likes to be told what to eat or do you prefer winging it?

I like to be told what to eat

I prefer winging it

7. Would you be open to walking or light yoga ONLY for 3 weeks?

Yes

8. Are you someone who cannot imagine living without red meat?

Yes

I would be open to trying

9. How often do you cook/prepare a meal for yourself?

I don’t cook

1-2 times a week

3-4 times a week

I do take out or uber eats

I cook every night of the week

10. How many times in the next month will you be forced to eat in a restaurant?

I don’t have any travel plans and will not be eating in any restaurant in the next month

1-2 times a month

3-4 times a month

I have extensive travel in the next month and will be eating out quite a bit!

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