Interested in The Hormone Balance Blueprint? Drop your info below and share some additional information about yourself in order to receive your free gift + personalized recommendations from Dr. Nicole!

First Name *

Last Name *

Phone

Email *

If you wish to receive some additional nutritional recommendations that could assist you on your journey, 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.

Age

If selected "OTHER" above, please explain here:

Do you experience any of these common skin issues? (Check all that apply)

How important is it to you to fix areas you struggle in right now?

Have you experienced any significant emotional/mental stressors in your life (examples: increased family stress, demanding job, caring for elderly parent or special needs child, difficult divorce)

Is there something specific you are looking for? (Peptides such as GLP-1/GIP, BPC-157, GHK-Cu &/or Hormone Replacement Therapy such as Estrogen Patches, Testosterone Injections, General Nutritional Support/Vitamin Recommendations?)

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 7C):

Failing memory with age

Increased sex drive

Episodes of tension in the head

Decreased tolerance to sugar

Check all that apply (Group 7E):

Dizziness

Headaches

Hot flashes

Abnormal hair growth on face or body (females)

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. Suggestions provided by Dr. Nicole Stewart are exactly that, suggestions. 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.

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By checking this box, I consent to receive non-marketing text messages from Dr. Nicole Stewart about my nutrition suggestions and the Blueprint program. 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.