Metabolic Bloom Quiz

Step 1 of 12

What is your gender?*

Female

Male

Stage of Life

What reproductive stage are you in?*

Pre-menopause - you’re still having regular periods and haven’t noticed big hormonal changes yet

Perimenopause - Your periods are starting to change or become irregular, and you may notice some shifty symptoms

Postmenopause - It's been a year or more since you’ve had a period

What is your age?*

Please enter a number less than or equal to 99.

Diet History & Metabolic Stress

How do you feel about your current weight?*

I’m happy with my weight where it is

I need to lose 20 lbs or less

Lose 20-50 lbs

Lose 50-100 lbs

Lose Over 100 lbs

What best describes your body type?*

Hourglass: Balanced on top and bottom with a defined waist.

Pear: Fuller through the hips with a narrower waist and shoulders.

Apple: More fullness through the middle, with slimmer hips and legs.

Athletic: Naturally lean or muscular with broader shoulders.

How old were you when you first tried to lose weight?*

Over 40

30–39

20–29

Under 20

Which types of diet or weight loss approaches have you tried? (Select all that apply)*

Commercial weight loss programs (ex. WW, Noom, Jenny Craig, Nutrisystem, etc.)

Weight loss medications

Meal replacement shakes or bars

Keto or low carb

Very Low Calorie Diets (VLCD) 800 calories/day or fewer

HCG injections or “skinny shots”

Fasting

How many times have you dieted in your past?*

0–2

3–5

6–9

10+

Health & Diagnosed Conditions

Have you ever been diagnosed with or treated for any of the following?

High blood pressure, cholesterol, or cardiovascular disease

Type 2 diabetes, prediabetes, or insulin resistance

Autoimmune (arthritis, lupus, psoriasis, etc.)

Thyroid Conditions (hyperthyroidism, hypothyroidism, Graves’, Hashimotos, etc.)

Other hormone imbalances (PCOS, Cushing's, Fibroids, Endometriosis, etc.)

Anxiety or depression

Sleep disorders

Histamine disorders (asthma, allergies, eczema, etc.)

Gerd, IBS, gallbladder

Neurological disease (MS, parkinsons, etc.)

Have you ever been diagnosed with or treated for any of the following?

High blood pressure, cholesterol, or cardiovascular disease

Type 2 diabetes, prediabetes, or insulin resistance

Autoimmune (arthritis, lupus, psoriasis, etc.)

Thyroid Conditions (hyperthyroidism, hypothyroidism, Graves’, Hashimotos, etc.)

Anxiety or depression

Sleep disorders

Histamine disorders (asthma, allergies, eczema, etc.)

Gerd, IBS, gallbladder

Neurological disease (MS, parkinsons, etc.)

Lifestyle Stressors

Which lifestyle factors apply to you right now?*

High-stress job or caregiving role

Poor or irregular sleep

Frequent travel or shift work

Economic stress or job instability

Chaotic family dynamics

I can’t find time for healthy habits

Aggressive daily exercise or athletic training

Symptoms

Which of the following symptoms are you experiencing?*

Stubborn weight gain

Bloating

Gas

Constipation

Cold hands/feet

IBS symptoms

Sugar or salty/crunchy cravings

Eating out of boredom/stress

Joint pain

Difficulty falling asleep

Waking up in the middle of the night

Hair thinning

Dry, itchy skin

Hot flashes

Breast tenderness

Night sweats

Low energy

Migraines

Brain fog

Anxiety

Mood swings

Vaginal dryness

Low libido

Food sensitivities or allergies

Skin rashes

Which of the following symptoms are you experiencing?*

Stubborn weight gain

Bloating

Gas

Constipation

IBS symptoms

Sugar or salty/crunchy cravings

Eating out of boredom/stress

Joint pain

Difficulty falling asleep

Waking up in the middle of the night

Hair thinning

Brittle nails

Dry, itchy skin

Erectile dysfunction

Low energy

Migraines

Brain fog

Anxiety

Mood swings

Low libido

Food sensitivities or allergies

Skin rashes

Let’s Get Your Results! Final Question: Contact Information

First Name*

Last Name*

Email*

Phone*

State*

Consent*

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