GLP + Me

Complete the Process

Decided to join us?! We're so glad you are here!

Please complete the information below to receive your recommendations

and suggestions upon the purchase of your product/program.

Let's Get Your Profile Completed

Dr. Nicole reviews each form personally, so please allow 24 business hours for a reply. An email will be sent to the one you provide below that will include additional recommendations or supplement suggestions based on the answers your provide.

First Name

Last Name

Age

Phone

Email *

Please fill out the following to the best of your ability. This will help to determine what additional support might be needed. Check all that apply. You may see some issues repeated, please still select as each section tells me something different. The information you share with me (Dr. Nicole Stewart) is never shared with anyone else.

Are you currently experiencing any of the following?

Bloating

Gut health challenges

Low energy/fatigue

Weight management

Difficulty focusing

Desire to increase protein intake

Trouble sleeping

Desire to reduce stress

Menopausal symptoms

Other

If selected "OTHER" above, please explain here:

Any allergies?

What is/are your area(s) of interest? *

General Nutritional Support

Natural GLP-1 Support/Supplements

Other

Check all that apply (Group 1):

Acid foods upset

Get chilled often

Dry mouth, eyes, nose

Feel "keyed up" with difficulty calming down

Extremities cold, clammy

Strong light is irritating

"Nervous" stomach

Reduced appetite

"Sour" stomach

Staring, blink little

Check all that apply (Group 2):

Joint stiffness after arising

Muscle, leg, toe cramps at night

Watery eyes or nose

Eyelids blink often and/or are swollen, puffy

Indigestion soon after meals

Always seem hungry

Rapid digestion (using bathroom soon after eating)

"Slow starter" (slow getting going in the mornings)

Sensitive to cold/get "chilled to the bone"

Upper respiratory challenges occur often

Check all that apply (Group 3):

Eat when nervous

Excessive appetite

Irritable between meals

Get "shaky" if hungry

Fatigue relieved by eating

Get lightheaded if meals delayed

Heart palpitations if meals missed or delayed

Fatigue in the afternoon

Wake after a few hours of sleep, then difficulty getting back to sleep

Mood of "blues" or melancholy

Check all that apply (Group 4):

Hands and feet go to sleep easily (numbness)

Sigh frequently, "air hunger"

Feeling the need to open windows in a closed room

Immune system challenges

Yawn frequently in the afternoons

Get "drowsy" often through day

Swollen ankles, worse at night

Muscle cramps, worse during exercise ("charley horse")

Noises in head or "ringing in ears"

Skin discolors easily after impact

Check all that apply (Group 5):

Dizziness often

Dry skin

Feeling of burning in feet

Frequent itching skin and feet

Hair loss

Occasional skin rashes

Bitter, metallic taste in mouth (especially in mornings)

Excessive worrier, feeling of insecure

Nausea after eating / foods upset stomach

Sneezing attacks

Check all that apply (Group 6):

Loss of taste for meat

Lower bowel gas several hours after eating

Burning stomach sensations that eating relieves

Pass large amounts of foul-smelling gas

Coating on tongue

Indigestion 1/2 to 1 hour after eating; may be up to 3-4 hours after eating

Watery or loose stool

Gas shortly after eating

Stomach "bloating"

Check all that apply (Group 7A):

Difficulty sleeping

A feeling of being "on edge"

Can't gain weight

Intolerance to heat

Feel highly emotional

Skin flushes easily

Night sweats

Increased appetite without weight gain

Eyelids and face twitch

Check all that apply (Group 7B):

Increase in weight

Decrease in appetite

Fatigue easily

Ringing in ears

Reduced/lack of initiative

Sensitive to cold

Dry/scaly skin

Hair coarse, falls out

Tension in head upon arising that wears off during the day

Check all that apply (Group 7C):

Failing memory with age

Increased sex drive

Episodes of tension in the head

Decreased tolerance to sugar

Check all that apply (Group 7D):

Abnormal increased thirst

Bloating of abdomen

Weight gain around hips or waist

Sex drive reduced or lacking

Tendency for stomach issues

Immune system challenges

Menstrual disorders

Check all that apply (Group 7E):

Dizziness

Headaches

Hot flashes

Abnormal hair growth on face or body (females)

Check all that apply (Group 7F):

Weakness, dizziness

Tired throughout the day, despite resting

Nails weak

Sensitive skin

Stiff joints

Increased perspiration

Poor circulation

Discomfort with bowel movements

Crave salt

Breathing challenges

Check all that apply (Group 8):

Muscle weakness

Lack of stamina

Drowsiness after eating

Heart races

Hyperirritable

Feeling of a band around the head

Feeling of sadness (melancholia)

Swelling of ankles

Change in urinary function

Night sweats

Check all that apply (FEMALE ONLY):

Very easily fatigued

Premenstrual tension

Menses more painful than usual

Depressed feelings before menstruation

Painful breasts during menses

Menstruate too frequently

Hysterectomy/ovaries removed

Menopausal hot flashes

Menses scanty or missed

Acne, worse at menses

Check all that apply (MEN ONLY):

Less involved in exercise

Less social

Difficult to postpone urination

Weak urinary system

Feeling of "blues" or melancholy

Lack of energy

Muscles in arms and legs seem softer/smaller

Tire too easily

Avoid activity

Leg nervousness at night

Anything else you would like to let Dr. Nicole know about?

By signing below, I understand that this does not establish an ongoing patient-provider relationship between myself and Dr. Nicole Stewart/Elara Functional Health. This form is voluntary and complementary and is used for educational and informational purposes only. Recommendations provided by Dr. Nicole Stewart/Elara Functional Health are exactly that, recommendations. I understand that I should check with my primary care healthcare provider if I have any questions about starting a new program. I understand that I can ask questions about product ingredients and usage to Dr. Nicole at any time. If I wish to establish a provider-patient relationship and take a deeper look at my health history and create a more detailed provider led program, I understand that I can go to drnicolestewart.janeapp.com and book an in-person or virtual DISCOVERY SESSION.

By checking this box, I consent to receive non-marketing messages from Dr. Nicole Stewart [Elara Functional Health ] about my nutrition recommendations. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others at the email provided, from Dr. Nicole Stewart [Elara Functional Health ] you will not be spammed and can opt out at any time.