Health Clarity Survey | Khristina Maureen

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Welcome. Let's begin with clarity.

Before we schedule your Clarity Session, I'd like to understand what you're navigating and whether this approach is the right fit.

This is not a medical intake. It simply helps us use our time intentionally.

First name*

Last name

Email*

Phone

Birthday

Month

Day

Year

What feels most frustrating about your health right now?

What are your main goals for seeking Functional Nutrition Counseling? (Select all that apply)

Support with a specific condition (IBS, PCOS, joint pain, etc.)

Weight loss, more energy, or a general sense of feeling "off"

Ongoing symptoms without clear answers

A fresh, root-cause approach after working with other practitioners

Other:

What have you tried so far?

I’m just beginning to explore support

I’ve tried a few strategies but feel stuck

I’ve worked with multiple practitioners

I’ve tried protocols/diets and still feel off

☐ Other:

How would you describe your current relationship with food?

I eat mostly whole foods but still don’t feel like myself

I struggle with consistency

I rely heavily on convenience or takeout

I’ve tried multiple diets and feel confused

☐ Other :

What percentage of your meals are home-cooked (versus takeout, dining out, or pre-made meals)?

Less than 25%

25–50%

50–70%

70–100%

Are you prepared to invest in structured 1:1 support if it feels aligned? *

YES – I’m ready to take action with support

NO – I’m mostly looking for quick fixes or specific supplement advice

Which statement resonates most?

I’m looking for quick fixes or specific supplement advice

I want to understand patterns before making changes

I’m not sure what I need yet

In a few sentences, what would meaningful progress look like for you?

This helps me understand what matters most to you.

**Khristina Maureen, CFNC, RDH, Board‑Certified Holistic Health Practitioner (AADP), Certified Aromatherapist

All content and services are for educational and wellness purposes only and not intended to diagnose, treat, cure or prevent any medical condition. Please consult your licensed healthcare provider before making changes to your diet, supplements, or routine.

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