Program Application

First name

Last name

Phone

Address

What are your primary goals for wanting to join this program? (e.g., clear skin, age gracefully, weight loss, parasite cleanse, muscle gain, managing a health condition)

Do you have any symptom concerns or diagnosed medical conditions? (e.g., diabetes, PCOS, fibromyalgia, hypertension, thyroid issues)

Are you currently taking any medications or supplements? Please list them.

Do you have any digestive issues? (e.g., IBS, Crohn's disease) How often do you have a BM and at what time of the day?

What is your occupation? Describe your typical workday. (e.g., sedentary, active)

Do you smoke or vape? Do you consume alcohol? If yes, how frequently and how much?

How often do you eat out or order takeout?

How many meals do you eat per day? Describe your typical daily meals and snacks. Include portion sizes if possible.

Do you follow any specific dietary plans? (e.g., carnivore, vegetarian, vegan, keto) Do you have any food preferences or aversions?

How would you rate your current nutritional knowledge? (e.g., beginner, intermediate, advanced)

What motivates you to join this program and achieve these goals? Do you have any specific short-term and long-term goals?

Skincare redefined— Functional Esthetics integrates body, mind, and soul for longevity

Program Application

Skincare redefined—
Functional Esthetics integrates
body, mind, and soul for longevity