Page 1 of 3

Fasting application

This application will help us both understand if we’re the right fit for working together. I’d love for you to answer the questions honestly, so I can offer the best possible guidance. If I feel we’re a good match, I’ll send you a link to schedule a call.

Full Name

*

Location (country & time zone)

*

Email

*

Phone number

*

Age

*

Age

A

Under 25

B

25-34

C

35-44

D

45-54

E

55-64

F

65+

Health & Fasting Background

Have you ever done any type of fasting before?

*

Have you ever done any type of fasting before?

Intermittent fasting (e.g., 16:8, OMAD)

Water fasting (24 hours or more)

Extended water fasting (3+ days)

Dry fasting

Partial fasting (e.g., Daniel Fast, juice fasting)

I am new to fasting

What is your primary goal for fasting?

*

What is your primary goal for fasting?

Weight loss

Healing from a specific condition (e.g., autoimmune, gut issues, diabetes, etc.)

Hormonal balance

Longevity & anti-aging

Spiritual growth

Detox/reset

Other

Do you have any medical conditions that could impact fasting?

*

Do you have any medical conditions that could impact fasting?

A

Yes

B

No

Are you currently taking any medications that require food?

*

Are you currently taking any medications that require food?

A

Yes

B

No