anALYZE Assessment

Pre-Intake Questionnaire

Help us understand your full health picture so we can build your personalized care plan.

Section 1 of 10
Section 1
Contact information
Section 2
Health history
Past and current diagnoses, medications, and care.
Have you ever been diagnosed with any of the following?
Select all that apply
Major illnesses, surgeries, or hospitalizations
Select all that apply
Current medications & supplements
Select all that apply
Section 3
Family history
Patterns in your family reveal meaningful risk factors.
Select all that apply
Section 4
Current quality of life
A snapshot of how you're feeling day-to-day.
Section 5
Body systems
Current symptoms across key areas.
Digestive & gut
Select all that apply
Hormones & metabolism
Select all that apply
Female-specific questions
Select all that apply
Select all that apply
Male-specific questions
Select all that apply
Pain & inflammation
Select all that apply
Liver, detox & toxicity
Select all that apply
Section 6
Emotional & mental well-being
Your mental health is inseparable from physical health.
Over the past month, have you experienced:
Select all that apply
Stress & nervous system
Section 7
Lifestyle overview
Your daily habits shape your health more than anything else.
Diet
Select all that apply
Movement
Select all that apply
Substance use
Sleep detail
Select all that apply
Section 8
Mental performance baseline
Rate each item 0–10. This creates your personal mental performance profile, tracked over time.
Use the full scale:  0 = not at all / very low  ·  5 = moderate  ·  10 = very strong / consistently true
1 — Psychological skills & confidence
Mastery confidence — How confident are you that you can perform well when things get difficult?
Not at all confidentExtremely confident
5
Vicarious experience — When you see others succeed, how much does it increase your belief that you can too?
Not at allA great deal
5
Self-talk under pressure — How supportive is your self-talk when you are under pressure?
Very criticalVery encouraging
5
Emotional & physiological state — When you feel anxious or fatigued, how well can you still perform?
I fall apartI perform just as well
5
Imagery & focus — How clearly can you picture yourself executing well in challenging moments?
Not at allVery clearly
5
2 — Attention & nervous system regulation
Breath focus — How focused were you on your breathing during a recent stillness or rest moment?
Not focusedFully focused
5
Body awareness — How aware are you of your body (tension, relaxation, sensations) throughout the day?
Not awareVery aware
5
Attention recovery — How easy is it to bring your attention back when it drifts?
Very hardVery easy
5
Nervous system calm — Right now, how calm does your nervous system feel?
Very activatedVery calm
5
Reset confidence — How confident are you in your ability to reset yourself under pressure?
Not confidentVery confident
5
3 — Stress & resilience
Stress load — How high is your current life stress load?
Very lowExtremely high
5
Overwhelm — How overwhelmed do you feel by your current stress?
Not at allCompletely overwhelmed
5
Coping effectiveness — When you feel stressed, how effective are your coping strategies?
Not effectiveVery effective
5
Recovery — How well do you mentally and emotionally recover between hard days?
Very poorlyVery well
5
Bounce-back — When something goes wrong, how quickly do you bounce back?
Very slowlyVery quickly
5
4 — Motivation architecture
Autonomy — How much do your goals feel like your own choice?
Not at allCompletely
5
Competence — How capable do you feel at what you are trying to improve?
Not capableVery capable
5
Relatedness — How supported and connected do you feel in your health journey?
Not at allVery supported
5
Intrinsic motivation — How meaningful is this health journey to you personally?
Not meaningfulExtremely meaningful
5
Goal clarity — How clear are you about what you are working toward right now?
Not clearVery clear
5
5 — Performance readiness
Routine consistency — How consistent are your daily routines that support performance (sleep, focus, nutrition, recovery)?
Not consistentVery consistent
5
Self-talk quality — How helpful is your self-talk during challenging situations?
HarmfulVery helpful
5
Life interference — How much do your current life demands interfere with your health goals?
Not at allA great deal
5
Mental readiness today — How mentally ready do you feel to engage with your health right now?
Not readyFully ready
5
Sustainability confidence — How confident are you that you can sustain your health commitments for the next month?
Not confidentVery confident
5
Top priority
Section 9
Goals & expectations
Help us understand what success looks like for you.
Select all that apply
Select all that apply
Section 10
Final check-in
Last few questions before you submit.
Select all that apply
✓
Submitted

Thank you for sharing

Your practitioner will review your responses before your first session. A confirmation email is on its way.

What happens next

1. Your practitioner reviews your intake
2. You'll be contacted to schedule
3. Your personalized plan begins