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.
Current diagnoses
Select all that apply
Please specify:
Major illnesses, surgeries, or hospitalizations
Select all that apply
Please specify:
Current medications
Supplements & herbs
Allergies & prior care
Select all that apply
Please specify:
Section 3
Family history
Patterns in your family reveal meaningful risk factors.
Select all that apply
Please specify:
Section 4
Current quality of life
A snapshot of how you're feeling day-to-day.
Section 5
Body systems
Select your symptoms — then rate how severe each one feels.
Digestive & gut
Select all that apply — a severity slider will appear for each one you choose
Rate severity (1 = mild, 10 = severe)
Hormones & metabolism
Select all that apply — a severity slider will appear for each one you choose
Rate severity (1 = mild, 10 = severe)
Female-specific questions
Select all that apply
Select all that apply
Male-specific questions
Select all that apply
Pain & inflammation
Select all that apply — a severity slider will appear for each one you choose
Rate severity (1 = mild, 10 = severe)
Liver, detox & toxicity
Select all that apply — a severity slider will appear for each one you choose
Rate severity (1 = mild, 10 = severe)
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
Please specify:
Movement
Select all that apply
Please specify:
Substance use
Sleep
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  ·  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
Please specify:
Select all that apply
Please specify:
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