Staterra Custom Supplements Questionnaire

The following symptom-based wellness questionnaire allows us to better understand your unique, personal circumstances. It will take you roughly 3 – 4 minutes to complete. This information allows us to develop a custom formula tailored to your needs, and around any medications you’re on, in order to best support any mood imbalances. All information provided is kept completely confidential.
If you have any questions, please feel free to contact us: info@staterra.ca

Name*

Name

Last Name

Email*

(this is how we will contact you)

email address

Age*

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Height *

(specify cm or feet)

type here

Weight *

(specify kg or lb)

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Gender*

Female

Male

Other (please specify)

Write here

Please list the changes you are hoping to achieve with this supplement.*

(i.e.: hormonal wellness, weight loss, joint health, etc.)

type here

Location*

Please rate how often you experience the following:*

	Never (less than once per month)	Rarely (a few times a month)	Sometimes (once per week)	Frequently (a couple times a week)	Always (almost everyday)
	Never (less than once per month)	Rarely (a few times a month)	Sometimes (once per week)	Frequently (a couple times a week)	Always (almost everyday)
Have trouble thinking or concentrating
Have memory problems, forget things often, or experience "brain fog"
Lose your train of thought or the thread of conversations
Experience headaches and/or migraines
Have little energy to do things or feel tired a lot
Lost interest in the things that once brought you enjoyment
Feel depressed, blue or down
Do you experience rapid or irregular heart beats/palpitations
Feel fidgety or restless
Feel stressed
Anxious and/or worried feeling that's hard to control
Feel close to panic
Feel moody, angry or irritable
Have trouble sleeping at night

How would you describe your sleeping pattern?*

Sleep too much

Disrupted sleep

Insomnia

Normal sleeping pattern

Overall, in the past 28 days, how many days did your mental state cause you to miss school or work or leave you unable to carry out your normal daily responsibilities?*

0 days

1 day/month

2-3 days/month

4-7 days/month

over 7 days/month

Overall, in the past 28 days, how many days did your mental state cause you to miss school or work or leave you unable to carry out your normal daily responsibilities?*

0 days

1 day/month

2-3 days/month

4-7 days/month

over 7 days/month

Rate how frequently your current mental state has disrupted your performance of the following:*

(over the last 28 days)

	Never (less than once per month)	Rarely (a few times a month)	Sometimes (once per week)	Frequently (a couple times a week)	Always (almost everyday)
	Never (less than once per month)	Rarely (a few times a month)	Sometimes (once per week)	Frequently (a couple times a week)	Always (almost everyday)
Your work/school work
Your social life/leisure activities
Your family life/home responsibilities

Are you on hormonal treatments? (ie. Birth control, IUD, hormone replacement therapy etc.)*

Yes (please specify)

Write here

When was the first day of your last period?

(skip this question if it doesn't apply to you)

DD/MM/YYYY ×

Please rate how often you experience the following:

Do these PMS and/or mood symptoms occur around 5 days before your period?*

Yes

Does not apply

How do you characterize your menstrual cycle?*

Regular

Irregular

Sudden change in menstrual patter

Menstruation has stopped

Does not apply

Are you trying to get pregnant, pregnant or breast feeding?*

Does not apply

Yes (please specify)

Write here

Do you struggle with weight fluctuations?*

Gain weight easily

Trouble loosing weight (even with diet and exercise)

Sudden lost of weight for no known cause

Please rate how often you experience the following:*

	Does not apply	Never (less than once per month)	Rarely (a few times per month)	Sometimes (once per week)	Frequently (a couple times a week)	Always (almost everyday)
	Does not apply	Never (less than once per month)	Rarely (a few times per month)	Sometimes (once per week)	Frequently (a couple times a week)	Always (almost everyday)
Menopause Symptoms (hot flashes, night sweats, vaginal dryness)
Experience diminished sex drive
Experience muscle cramps (legs, hands, feet)
Feel distinctly sluggish/lethargic

Please rate how often you experience the following:*

	Never (less than once per month)	Rarely (a few times per month)	Sometimes (once per week)	Frequently (a couple times a week)	Always (almost everyday)
	Never (less than once per month)	Rarely (a few times per month)	Sometimes (once per week)	Frequently (a couple times a week)	Always (almost everyday)
Experience constipation (difficulty passing bowel movements)
Experience diarrhea (liquid bowel movements)
Experience bloating, gas, cramping, and/or abdominal pain
Suffer from joint and/or generalized body pain
Experience indigestion or heartburn
Experience from worsening allergies, eczema, or asthma or get frequent colds and sinusitis
Experience watery stool

How often do you experience bowel movements?Radio Options Title*

1 - 4 times a day

More than 5 times a day

Once every couple of days

Less than every couple of days

Please provide us with a brief description of your average breakfast, lunch, dinner, and snacks:*

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Do you take any medications?*

Yes (please provide the brand NAME, DOSAGE and DURATION OF USE for each medication

Write here

Please include any additional information not covered that you think we should know here:

(food allergies, medical conditions, sensitivities, etc)

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By checking this circle, you agree to the following: 1.) That the information you provided is true and complete to the best of your knowledge. 2.) That our Customized Supplements program, or any products, services, or information offered by Staterra, is not intended to provide diagnosis, treatment or medical advice. Please consult with your healthcare professional regarding any medical or health related diagnosis or treatment options.*

Yes, I agree.

Have you purchased the Customized Supplements from us before?*

Yes

How did you hear about us?*

type here

Please rate how often you experience the following:

Your form has been submitted