Name/Age/Sex *

Email *

Main Concern *

Current Symptoms *

What are your main symptoms?

Sleep *

difficulty falling asleep? waking up at 3-4am? vivid dreams? tired on waking?

Digestion *

bloating?constipation?loose stools? acid reflux? appetite?

Energy Level/EMOTIONS/STRESS *

fatigue? low motivation?

Temperature

cold hands/feet? night sweats? heat sensation? feeling cold easily?

Menstrual Cycle/ Fertility Goals

cycle length? painful periods? clotting? PMS? trying to conceive? IVF history? pregnancy history?

Current Supplements or Medication

Please upload a clear tongue photo in natural daylight before eating or brushing tongue. *

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Please upload a clear tongue photo in natural daylight

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Thanks for getting in touch!

Thank you for your consultation request.

We will review your form and contact you within 24 hours.

Have a great day!

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