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Functional Wellness Self-Assessment

This self-assessment is designed to help you reflect on how your body has been functioning across key areas of wellness. It is not a diagnosis tool. Your answers help identify patterns in energy, digestions, sleep, mood, and overall resilience so we can better understand where support may be needed.

Name

Email

Age Range

Age Range
A
B
C
D
E
F

What brought you to this assessment today?

Energy & Fatigue Patterns

I feel low energy during the day

I feel low energy during the day
A
B
C
D
E

I rely on caffeine to function.

I rely on caffeine to function.
A
B
C
D
E

I feel tired even after a full night of sleep.

I feel tired even after a full night of sleep.
A
B
C
D
E

I experience energy crashes after meals

I experience energy crashes after meals
A
B
C
D
E

I feel mentally foggy or slow

I feel mentally foggy or slow
A
B
C
D
E

Sleep Quality

I have trouble falling asleep

I have trouble falling asleep
NeverSometimesAlmost Always

I wake up during the night/

I wake up during the night/
NeverSometimesAlmost Always

I wake up feeling unrefreshed.

I wake up feeling unrefreshed.
NeverSometimesAlmost Always

I wake up between 1-3am consistently

I wake up between 1-3am consistently
NeverSometimesAlmost Always

I have a hard time staying asleep due to racing thoughts.

I have a hard time staying asleep due to racing thoughts.
NeverSometimesAlmost Always

Digestion & Gut Health

I experience bloating after meals.

I experience bloating after meals.
NeverSometimesAlmost Always

I have irregular bowel movements

I have irregular bowel movements
NeverSometimesAlmost Always

I experience constipation or diarrhea

I experience constipation or diarrhea
NeverSometimesAlmost Always

I feel discomfort after eating certain foods

I feel discomfort after eating certain foods
NeverSometimesAlmost Always

I have frequent gas or abdominal pressure

I have frequent gas or abdominal pressure
NeverSometimesAlmost Always

Do you notice any trigger foods?

Mood & Nervous System

I feel anxious or overwhelmed easily

I feel anxious or overwhelmed easily
NeverSometimesAlmost Always

I experience mood swings

I experience mood swings
NeverSometimesAlmost Always

I feel mentally burned out

I feel mentally burned out
NeverSometimesAlmost Always

I have trouble relaxing even when resting

I have trouble relaxing even when resting
NeverSometimesAlmost Always

I feel emotionally reactive or sensitive

I feel emotionally reactive or sensitive
NeverSometimesAlmost Always

Hormonal & Body Signals (optional but powerful)

I experience irregular cycles or hormonal shifts (if applicable)
Hormonal & Body Signals (optional but powerful)
NeverSometimesAlmost Always

I notice skin changes (acne, dryness, etc.)

I notice skin changes (acne, dryness, etc.)
NeverSometimesAlmost Always

I experience temperature sensitivity (hot/cold easily)

I experience temperature sensitivity (hot/cold easily)
NeverSometimesAlmost Always

I have changes in libido or reproductive energy

I have changes in libido or reproductive energy
NeverSometimesAlmost Always

I experience water retention or unexplained weight changes.

I experience water retention or unexplained weight changes.
NeverSometimesAlmost Always

Immune & Inflammation Patterns

I get sick frequently.
Immune & Inflammation Patterns
NeverSometimesAlmost Always

I take longer than expected to recover from illness

I take longer than expected to recover from illness
NeverSometimesAlmost Always

I experience joint stiffness or body aches

I experience joint stiffness or body aches
NeverSometimesAlmost Always

I notice seasonal allergies or sensitivities.

I notice seasonal allergies or sensitivities.
NeverSometimesAlmost Always

I feel generally inflamed or "puffy" in the body.

I feel generally inflamed or "puffy" in the body.
NeverSometimesAlmost Always

Lifestyle Inputs

Daily Stress Level
Lifestyle Inputs
No StressSome StressConstant Stress

Average sleep per night

Average sleep per night
A
B
C
D
E

Movement level

Movement level
A
B
C
D

Hydration

Hydration
A
B
C

Open Reflection

What symptom feels most disruptive in your life right now?

If your body could communicate one message clearly, what do you think it would say?

Anything else you want me to know?

Would you like a guided interpretation of your results?

Would you like a guided interpretation of your results?