Wellness Form

Please fill out this form so we can provide you with specific recommendations to help you!

First Name

Last Name

Age

Phone

Email *

Drop your social media handle to connect on online:

If selected "OTHER" above, please explain here:

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

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

General Nutritional Support

Natural GLP-1 Support/Supplements

Other

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)

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.

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 a 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.

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