What is your name?

What is your email address?

Enter email then go to next

What is your age?

Resident country

Can only select one.

Gender

Can only select one.

Enter your weight (KG)

Enter your height (CM)

What's your primary health goal?

Select up to 3 options

How active are you?

How many days per week do you exercise?

Rate your stress levels

0
Relaxed 10
Highly Stressed
5

Rate your energy levels

0
Very Poor Energy 10
Highly Energised
5

Sleep

Hours Per night

0 10
5

Quality

0 10
5

Do you have any health conditions?

Do you suffer from any of the following symptoms?

What supplements are you already taking?

Do you have any allergies?

Did your doctor recommend an iron supplement recently?

Are you taking any medication?

Please note any hormonal contraception like the pill, coil etc.

How many times per week do you eat oily fish?

0 7
4

Do you follow a plant-based diet

Vegan / Vegetarian

How many portion of vegetables/fruit do you eat per day?

0 10
5

Are you trying to conceive?

How many units of alcohol do you consumer per week?

(1 pint of beer= 2.3 units, 175ml glass of wine = 2.3 units, 25ml of spirit = 1 unit)

Are you pregnant or breasfeeding?



Do you suffer from premenstrual syndrome (PMS)?

Please give detail about your menstrual cycle

Where did you hear about Your Wellness Collective?

Select all that apply

Please disclose any further information you deem necessary
for our team to provide you with the most tailored supplement plan