What’s been challenging? *

Low immunity or getting sick often

Hormone or menstrual balance

Low energy or brain fog

Digestive issues

Allergies

Trouble sleeping

Stress / anxiety

Other

How often do you feel run down or sick? *

Rarely

A few times a year

Often – I get sick easily

How’s your sleep lately? *

Great – I sleep well most nights

Okay – sometimes restless

Not good – hard to fall or stay asleep

Are you currently taking any medications or supplements? *

Yes

No

How long have you been dealing with this? *

Less than 6 months

6–12 months

1–3 years

3+ years

What have you already tried that didn't work? *

Melatonin

Probiotics

Multivitamins

Ashwagandha

Prescription meds

Nothing yet

Others

How much do you spend on supplements per month? *

$0

Under $25

$25–50

$50–100

$100+

What’s the main thing you’d like us to help you improve through herbs? (optional)

First Name *

Last Name *

Email *

Phone *

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