Health Protocol Intake Form

Let's start by generating your secure resume link

Enter your email now. We'll create a unique session ID so you can save progress and return anytime.

Safety & suitability check

These questions help us screen for situations that require urgent care or 1:1 clinical support.

Age

18 years or older Under 18

Pregnancy / breastfeeding / trying to conceive

None of these apply Currently pregnant Currently breastfeeding Actively trying to conceive

Red-flag symptoms (select all that apply)

If any of these are present, we'll recommend urgent medical review before self-guided protocols.

None of these apply Unexplained chest pain / pressure Blood in stool/urine or unexplained bleeding Unintentional weight loss >10% in 6 months New neurological symptoms (vision changes, weakness, numbness) Severe vomiting/diarrhoea with dehydration I feel unsafe / in a mental health crisis right now

Complex conditions (select all that apply)

These don't always stop the intake, but may trigger a "consult recommended" note.

None of these apply Cancer (past or current) Inflammatory bowel disease (Crohn's/UC) Kidney disease Liver disease Autoimmune condition High-risk pregnancy / breastfeeding complications

Medication interaction flags (select all that apply)

This helps us avoid common supplement–medication interaction risks.

None Blood thinners / anticoagulants / antiplatelets MAOI antidepressants Immunosuppressants Thyroid medications Diabetes medications Blood pressure medications

Important: please seek medical support first

Based on your answers, a self-guided protocol is not appropriate right now. If this is urgent or life-threatening, call emergency services (000).

Your details

This helps personalise timing, language, and recommendations.

Consent & scope

These are required to proceed.

I understand this is educational support and not medical diagnosis or treatment. I confirm my answers are accurate to the best of my knowledge. I understand I should not change prescribed medications without my GP/specialist. I consent to the collection and use of my information to produce my personalised protocol (see Privacy Policy).

Your goals

Choose one primary goal, plus up to two secondary goals.

Primary goal

Energy / fatigue Sleep Digestion / gut Stress / mood Weight / body composition Skin Hormone support General wellness / prevention

Secondary goals (optional, max 2)

Pick any additional areas you want the protocol to consider.

Energy / fatigue Sleep Digestion / gut Stress / mood Weight / body composition Skin Hormone support General wellness / prevention

In 4 weeks, success looks like…

Tip: use concrete outcomes (sleep latency, bowel regularity, cravings, mood stability, energy crashes, etc.).

Optional: in 12 weeks, success looks like…

Budget, change capacity, and barriers

Change tolerance

1–2 small changes (keep it simple) 3–4 changes (some bandwidth) All-in (ready for major change)

Biggest barriers (select all that apply)

Time Cost Consistency Overwhelm Lack of support None

Motivation (0–10) 5

Readiness

Willingness to modify diet significantly (1–5)

Willingness to take multiple supplements daily (1–5)

Willingness to keep food/symptom logs (1–5) (optional)

Confidence to follow through (0–10) 5

What might get in the way? (optional)

Medical history

Other diagnoses (optional)

Surgeries / major procedures (optional)

Allergies / intolerances (optional)

Family history (optional)

Diabetes Heart disease / stroke Autoimmune disease Cancer

Oral / dental health

Oral inflammation can influence systemic inflammation and overall health.

No current dental issues Yes (answer the next two questions)

Environmental factors (optional)

These questions are optional and help identify common root-cause contributors. (Shown when relevant goals are selected.)

Possible mould exposure (home/work) Occupational chemical exposure Frequent pesticide/solvent exposure Amalgam (silver) fillings

Water source (optional)

Notes (optional)

Symptom wizard

First, tell us which clusters apply. Then we'll ask severity and frequency only for those.

When did these issues begin? (approx.)

Quick mental wellbeing check (2 questions)

Over the last 2 weeks, how often have you been bothered by:

Feeling nervous, anxious, or on edge

Not being able to stop or control worrying

Medications

This is critical for interaction checks.

No medications Yes — prescription medications Only over-the-counter medications

Current supplements

List anything you currently take (including vitamins, herbs, protein powders, sleep aids).

Past bad reactions (optional)

Nutrition patterns (Improved Plate Builder)

Structured options help us identify high-leverage changes without long free-text.

Breakfast pattern

Lunch pattern

Dinner pattern

Snack habit

Eating pattern

Vegetable intake

Protein at meals

Primary protein sources (select main sources)

Red meat (beef, lamb, pork) Chicken / poultry Fish / seafood Eggs Legumes (beans, lentils) Tofu / tempeh Dairy (yogurt, cheese) Protein powder No regular source

Typical cooking methods (select all that apply)

Raw (salads) Steamed Grilled / BBQ Baked / roasted Fried (pan or shallow) Deep fried Microwave Air fryer

Ultra-processed foods

Water intake

Caffeine

Alcohol

Optional: anything else notable about diet?

Lifestyle

Usual bedtime

Usual wake time

Sleep quality (0–10) 5

Stress level (0–10) 5

Main stress sources (optional)

Coping strategies (optional)

Exercise pattern

Support & context

Living situation (optional)

Social support level (0–10) 5

Financial stress level (0–10) (optional) 0

Main support person (optional)

Meaning & fulfilment (optional)

No spiritual / religious practice Yes (optional details below)

Optional details

Sense of purpose (0–10) (optional) 5 Values alignment (0–10) (optional) 5

Gut deep dive

Shown because you selected a gut goal and/or gut symptom cluster.

Bowel pattern (best match)

Bloating timing

Antibiotics in last 12 months?

Notes (optional)

Hormone module

Shown because you selected a hormone goal and/or hormone symptom cluster (and/or relevant sex at birth).

Notes (optional)

Labs & uploads (optional)

If you have recent labs, uploading helps refine recommendations.

Upload files (PDF/images)

Any lab notes (optional)

Preventive care (optional light touch)

This helps align "general wellness / prevention" recommendations.

Blood pressure checked recently Cholesterol/lipids recently Glucose/HbA1c recently Skin check Bowel screening Cervical screening Not sure

Practicality

We match your protocol to your real life.

Minimal (3–5 actions) Balanced (5–8 actions) Comprehensive (8–12 actions)

Cooking ability

Time available for food prep

Review & submit

Confirm your key details before submitting.

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I understand this is educational and tailored to the info I provided. I'm ready to submit and receive my protocol within 5 business days.

Success — intake submitted ✓

Your custom protocol takes up to 5 business days. While you wait, you can start with the basics today.

Download: Foundation Guide
Hydration, sleep, and simple wins you can start tonight. Optional: 7-Day Food & Symptom Log
If you complete this, you can reply to your delivery email with it for refinement.

Quick feedback (optional)

How clear were the questions? (1–5)

Anything confusing or missing? (optional)

Send weekly check-in reminders while I'm waiting for the protocol.

Your Personalized Protocol Starts Here

Let's start by generating your secure resume link

Safety & suitability check

Important: please seek medical support first

Your details

Consent & scope

Your goals

Budget, change capacity, and barriers

Medical history

Oral / dental health

Environmental factors (optional)

Symptom wizard

Quick mental wellbeing check (2 questions)

Medications

Current supplements

Nutrition patterns (Improved Plate Builder)

Lifestyle

Support & context

Meaning & fulfilment (optional)

Gut deep dive

Hormone module

Labs & uploads (optional)

Preventive care (optional light touch)

Practicality

Review & submit

Success — intake submitted ✓

Quick feedback (optional)