Gut Health Healing Plan
Name
Email
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
No
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
No
8. Are you someone who cannot imagine living without red meat?
Yes
No
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 days in the month of September will you be forced to eat in a restaurant?
I don’t have any travel plans and will not be eating in any restaurant for the month of Sept
1-2 times a month
3-4 times a month
I have extensive travel in Sept and will be eating out quite a bit!
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