Biology Questionnaire

This assessment is to learn about your BIOLOGY

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Question 1 of 77

What are your top 3 goals right now?

Paragraph answer

Question 2 of 77

What made you decide to do this now (what’s the “cost” of staying the same)?

Paragraph answer

Question 3 of 77

How motivated do you feel to change right now?

A

1

B

2

C

3

D

4

E

5

F

6

G

7

H

8

I

9

J

10

Question 4 of 77

Excessive worry / rumination (Select 3 answers: 1.) Frequency 2.) Severity 3.) Interference

(Select all that apply)

A

1.) Never

B

1.) Seldom

C

1.) Often

D

1.) Daily

E

2.) 0-3

F

2.) 3-5

G

2.) 5-7

H

2.) 8-10

I

3.) 0-3

J

3.) 3-5

K

3.) 5-7

L

3.) 8-10

Question 5 of 77

Panic symptoms / surges ( Choose 3 : 1.)Frequency (Never -> Daily) AND 2.)Severity (0-10) AND 3.)Interference (0-10).

(Select all that apply)

A

1.) Never

B

1.) Seldom

C

1.) Often

D

1.) Daily

E

2.) 0-3

F

2.) 3-5

G

2.) 5-7

H

2.) 7-10

I

3.) 0-3

J

3.) 3-5

K

3.) 5-7

L

3.) 8-10

Question 6 of 77

Irritability / on edge

(Select all that apply)

A

1.) Never

B

1.) Seldom

C

1.) Often

D

1.) Daily

E

2.) 0-3

F

2.) 3-5

G

2.) 5-7

H

2.) 8-10

I

3.) 0-3

J

3.) 3-5

K

3.) 5-7

L

3.) 8-10

Question 7 of 77

Low mood / sadness

(Select all that apply)

A

1.) Never

B

1.) Seldom

C

1.) Often

D

1.) Daily

E

2.) 0-3

F

2.) 3-5

G

2.) 5-7

H

2.) 8-10

I

3.) 0-3

J

3.) 3-5

K

3.) 5-7

L

3.) 8-10

Question 8 of 77

Loss of interest / pleasure

(Select all that apply)

A

1.) Never

B

1.) Seldom

C

1.) Often

D

1.) Daily

E

2.) 0-3

F

2.) 3-5

G

2.) 5-7

H

2.) 8-10

I

3.) 0-3

J

3.) 3-5

K

3.) 5-7

L

3.) 8-10

Question 9 of 77

Low motivation / can't initiate

(Select all that apply)

A

1.) Never

B

1.) Seldom

C

1.) Often

D

1.) Daily

E

2.) 0-3

F

2.) 3-5

G

2.) 5-7

H

2.) 8-10

I

3.) 0-3

J

3.) 3-5

K

3.) 5-7

L

3.) 8-10

Question 10 of 77

Procrastination / avoidance

(Select all that apply)

A

1.) Never

B

1.) Seldom

C

1.) Often

D

1.) Daily

E

2.) 0-3

F

2.) 3-5

G

2.) 5-7

H

2.) 8-10

I

3.) 0-3

J

3.) 3-5

K

3.) 5-7

L

3.) 8-10

Question 11 of 77

Distractibility

(Select all that apply)

A

1.) Never

B

1.) Seldom

C

1.) Often

D

1.) Daily

E

2.) 0-3

F

2.) 3-5

G

2.) 5-7

H

2.) 8-10

I

3.) 0-3

J

3.) 3-5

K

3.) 5-7

L

3.) 8-10

Question 12 of 77

Trouble sustaining focus

(Select all that apply)

A

1.) Never

B

1.) Seldom

C

1.) Often

D

1.) Daily

E

2.) 0-3

F

2.) 3-5

G

2.) 5-7

H

2.) 8-10

I

3.) 0-3

J

3.) 3-5

K

3.) 5-7

L

3.) 8-10

Question 13 of 77

Brain fog / mental haze

(Select all that apply)

A

1.) Never

B

1.) Seldom

C

1.) Often

D

1.) Daily

E

2.) 0-3

F

2.) 3-5

G

2.) 5-7

H

2.) 8-10

I

3.) 0-3

J

3.) 3-5

K

3.) 5-7

L

3.) 8-10

Question 14 of 77

Memory lapses

(Select all that apply)

A

1.) Never

B

1.) Seldom

C

1.) Often

D

1.) Daily

E

2.) 0-3

F

2.) 3-5

G

2.) 5-7

H

2.) 8-10

I

3.) 0-3

J

3.) 3-5

K

3.) 5-7

L

3.) 8-10

Question 15 of 77

Decision fatigue

(Select all that apply)

A

1.) Never

B

1.) Seldom

C

1.) Often

D

1.) Daily

E

2.) 0-3

F

2.) 3-5

G

2.) 5-7

H

2.) 8-10

I

3.) 0-3

J

3.) 3-5

K

3.) 5-7

L

3.) 8-10

Question 16 of 77

Impulsivity (spending, eating, reacting, scrolling)

(Select all that apply)

A

1.) Never

B

1.) Seldom

C

1.) Often

D

1.) Daily

E

2.) 0-3

F

2.) 3-5

G

2.) 5-7

H

2.) 8-10

I

3.) 0-3

J

3.) 3-5

K

3.) 5-7

L

3.) 8-10

Question 17 of 77

Emotional eating / cravings

(Select all that apply)

A

1.) Never

B

1.) Seldom

C

1.) Often

D

1.) Daily

E

2.) 0-3

F

2.) 3-5

G

2.) 5-7

H

2.) 8-10

I

3.) 0-3

J

3.) 3-5

K

3.) 5-7

L

3.) 8-10

Question 18 of 77

Sleepiness / fatigue in daytime

(Select all that apply)

A

1.) Never

B

1.) Seldom

C

1.) Often

D

1.) Daily

E

2.) 0-3

F

2.) 3-5

G

2.) 5-7

H

2.) 8-10

I

3.) 0-3

J

3.) 3-5

K

3.) 5-7

L

3.) 8-10

Question 19 of 77

Overwhelm / shutdown

(Select all that apply)

A

1.) Never

B

1.) Seldom

C

1.) Often

D

1.) Daily

E

2.) 0-3

F

2.) 3-5

G

2.) 5-7

H

2.) 8-10

I

3.) 0-3

J

3.) 3-5

K

3.) 5-7

L

3.) 8-10

Question 20 of 77

Top 3 symptoms impacting your life mos

(Select all that apply)

A

Excessive worry / rumination

B

Panic symptoms / surges

C

Irritability / on edge

D

Low mood / sadness

E

Loss of interest / pleasure

F

Low motivation / can't initiate

G

Procrastination / avoidance

H

Distractibility

I

Trouble sustaining focus

J

Brain fog / mental haze

K

Memory lapses

L

Decision fatigue

M

Impulsivity (spending, eating, reacting, scrolling)

N

Emotional eating / cravings

O

Sleepiness / fatigue in daytime

P

Overwhelm / shutdown

Question 21 of 77

Most common triggers (choose all that apply)

(Select all that apply)

A

Sleep loss

B

Stress/pressure

C

Conflict

D

Long gaps without food

E

High sugar/refined carbs

F

Caffeine

G

Alcohol

H

Certain foods

I

Hormonal cycle shifts

J

Overstimulation/noise

K

Pain/inflammation flare

L

Screen time overload

M

Perfectionism

N

Lack of structure

Question 22 of 77

When are you at your best? (time of day + conditions)

Paragraph answer

Question 23 of 77

When are you at your worst? (time of day + conditions)

Paragraph answer

Question 24 of 77

Which habits are currently keeping you stuck? (choose all)

(Select all that apply)

A

Late-night screens

B

Skipping meals

C

High caffeine

D

Alcohol to unwind

E

Low movement

F

Working without breaks

G

Negative self-talk

H

Avoidance

I

Disorganization/clutter

J

Other

Question 25 of 77

Your most common stress response

A

Fight (irritable/angry)

B

Flight (busy/anxious)

C

Freeze (stuck/shutdown)

D

Fawn (people-pleasing)

E

Mixed

Question 26 of 77

How quickly do you recover after stress?

A

Minutes

B

Hours

C

1-2 days

D

Several days

E

I don't feel like I recover

Question 27 of 77

What helps you regulate reliably? (choose all)

(Select all that apply)

A

Breathwork

B

Walking

C

Strength training

D

Cardio

E

Yoga/stretching

F

Meditation/prayer

G

Journaling

H

Therapy

I

Music

J

Nature

K

Cold/heat

L

Supplements

M

Sleep

N

Nothing works consistently

O

Other

Question 28 of 77

In the past 2 weeks, thoughts of self-harm or not wanting to be here?

A

Yes

B

No

Question 29 of 77

If yes: are you safe right now?

A

Yes

B

No

C

(Did not answer Yes in Previous question)

Question 30 of 77

I answered the previous two questions honestly

(Select all that apply)

A

Yes

B

No

Brain History

Question 32 of 77

History of concussion/head injury/whiplash

A

No

B

Yes

Question 33 of 77

If yes: count + approximate dates

Paragraph answer

Question 34 of 77

Loss of consciousness ever?

A

Yes

B

No

C

Not Sure

Question 35 of 77

Migraines or chronic headaches

A

Never

B

Ocassionally

C

Monthly

D

Weekly +

Question 36 of 77

Known neurological diagnosis (if any)

Paragraph answer

Question 37 of 77

Brain fog / slow thinking

A

None

B

Mild

C

Moderate

D

Severe

Question 38 of 77

Working memory issues

A

None

B

Mild

C

Moderate

D

Severe

Question 39 of 77

Word-finding issues

A

None

B

Mild

C

Moderate

D

Severe

Question 40 of 77

Mental fatigue

A

None

B

Mild

C

Moderate

D

Severe

Question 41 of 77

Sensory sensitivity (light/sound)

A

None

B

Mild

C

Moderate

D

Severe

Question 42 of 77

Emotional reactivity

A

None

B

Mild

C

Moderate

D

Severe

Question 43 of 77

Low frustration tolerance

A

None

B

Mild

C

Moderate

D

Severe

Question 44 of 77

Impulsivity

A

None

B

Mild

C

Moderate

D

Severe

Question 45 of 77

Social exhaustion

A

None

B

Mild

C

Moderate

D

Severe

Sleep + Circadian

Question 47 of 77

Average sleep hours/night

A

<5

B

5-6

C

6-7

D

7-8

E

8+

Question 48 of 77

Sleep quality (0-10)

Paragraph answer

Question 49 of 77

Sleep issues (choose all)

(Select all that apply)

A

Trouble falling asleep

B

Trouble staying asleep

C

Waking too early

D

Nightmares

E

Restless legs

F

Snoring

G

Possible apnea

H

Other

Question 50 of 77

Wake refreshed?

A

Never

B

Sometimes

C

Often

Neuroinflammation Signals

Question 52 of 77

Regular inflammation-type symptoms (choose all)

(Select all that apply)

A

None

B

Joint pain

C

Muscle aches

D

Chronic sinus issues

E

Skin rashes/eczema

F

Autoimmune diagnosis

G

Frequent infections

H

Allergy symptoms

I

Swelling/puffiness

J

Persistent fatigue

Question 53 of 77

Mold/water-damaged building exposure

A

Yes

B

No

C

Not Sure

Question 54 of 77

Long COVID / persistent post-viral symptoms

A

Yes

B

No

C

Not Sure

Attention Pattern Indicators (not diagnostic)

Question 56 of 77

Childhood focus/impulsivity or school struggles

A

Yes

B

No

C

Not Sure

Question 57 of 77

Rely on urgency/deadlines to perform

( 0-10 )

Paragraph answer

Question 58 of 77

Hyperfocus on interesting tasks but avoid boring ones

( 0-10 )

Paragraph answer

Current meds + supplements

Question 60 of 77

Current medications

Paragraph answer

Question 61 of 77

Current supplements

Paragraph answer

Gut-Brain Axis

Question 63 of 77

Weekly digestive symptoms (choose all)

(Select all that apply)

A

Bloating

B

Constipation

C

Diarrhea

D

Gas

E

Reflux/heartburn

F

Nausea

G

Food sensitivities

H

Abdominal pain

I

None

Question 64 of 77

Bowel movement frequency

A

<3/week

B

Once daily

C

2+ daily

D

Varies

Question 65 of 77

GI diagnoses (IBS/SIBO/IBD/celiac/GERD)

A

No

B

Yes

Question 66 of 77

If you answered YES , please list your diagnosis

Paragraph answer

Blood Sugar + Metabolic Signals

Question 68 of 77

Shaky/irritable/anxious if too long without food

(Rate 0-10)

Paragraph answer

Question 69 of 77

Crash after meals?

(Rate 0-10)

Paragraph answer

Question 70 of 77

Cravings (choose all)

(Select all that apply)

A

Sugar

B

Salt

C

Carbs

D

Late-night snacks

E

None

Question 71 of 77

Typical eating pattern

A

Regular meals

B

Skips breakfast

C

Grazing

D

One big meal

E

Irregular

Diet Quality Snapshot

Question 73 of 77

Daily protein servings

A

0-1

B

2

C

3

D

4+

Question 74 of 77

Vegetables daily? (servincgs)

A

0-1

B

2-3

C

4-5

D

6+

Question 75 of 77

Ultra-processed foods?

A

Never

B

1-2x/week

C

Most days

D

Daily

Question 76 of 77

Hydration/day

A

<40 oz

B

40-60 oz

C

60-80 oz

D

80+

Question 77 of 77

Alcohol frequency

A

Never

B

Monthly

C

Weekly

D

2-3x/week

E

4+

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Biology Questionnaire

Click the button below to start.

What are your top 3 goals right now?

What made you decide to do this now (what’s the “cost” of staying the same)?

How motivated do you feel to change right now?

Excessive worry / rumination (Select 3 answers: 1.) Frequency 2.) Severity 3.) Interference

Panic symptoms / surges ( Choose 3 : 1.)Frequency (Never -> Daily) AND 2.)Severity (0-10) AND 3.)Interference (0-10).

Irritability / on edge

Low mood / sadness

Loss of interest / pleasure

Low motivation / can't initiate

Procrastination / avoidance

Distractibility

Trouble sustaining focus

Brain fog / mental haze

Memory lapses

Decision fatigue

Impulsivity (spending, eating, reacting, scrolling)

Emotional eating / cravings

Sleepiness / fatigue in daytime

Overwhelm / shutdown

Top 3 symptoms impacting your life mos

Most common triggers (choose all that apply)

When are you at your best? (time of day + conditions)

When are you at your worst? (time of day + conditions)

Which habits are currently keeping you stuck? (choose all)

Your most common stress response

How quickly do you recover after stress?

What helps you regulate reliably? (choose all)

In the past 2 weeks, thoughts of self-harm or not wanting to be here?

If yes: are you safe right now?

I answered the previous two questions honestly

Brain History

History of concussion/head injury/whiplash

If yes: count + approximate dates

Loss of consciousness ever?

Migraines or chronic headaches

Known neurological diagnosis (if any)

Brain fog / slow thinking

Working memory issues

Word-finding issues

Mental fatigue

Sensory sensitivity (light/sound)

Emotional reactivity

Low frustration tolerance

Impulsivity

Social exhaustion

Sleep + Circadian

Average sleep hours/night

Sleep quality (0-10)

Sleep issues (choose all)

Wake refreshed?

Neuroinflammation Signals

Regular inflammation-type symptoms (choose all)

Mold/water-damaged building exposure

Long COVID / persistent post-viral symptoms

Attention Pattern Indicators (not diagnostic)

Childhood focus/impulsivity or school struggles

Rely on urgency/deadlines to perform ( 0-10 )

Hyperfocus on interesting tasks but avoid boring ones ( 0-10 )

Current meds + supplements

Current medications

Current supplements

Gut-Brain Axis

Weekly digestive symptoms (choose all)

Bowel movement frequency

GI diagnoses (IBS/SIBO/IBD/celiac/GERD)

If you answered YES , please list your diagnosis

Blood Sugar + Metabolic Signals

Shaky/irritable/anxious if too long without food (Rate 0-10)

Crash after meals? (Rate 0-10)

Cravings (choose all)

Typical eating pattern

Diet Quality Snapshot

Daily protein servings

Vegetables daily? (servincgs)

Ultra-processed foods?

Hydration/day

Alcohol frequency

Confirm and Submit

Rely on urgency/deadlines to perform

( 0-10 )

Hyperfocus on interesting tasks but avoid boring ones

( 0-10 )

Shaky/irritable/anxious if too long without food

(Rate 0-10)

Crash after meals?

(Rate 0-10)