Microdosing Health Assessment And Safety Questionnaire

Before we begin, this assessment will help determine if microdosing is a good fit for you. It includes questions about your health, medications, and personal goals. Your responses are private and will help customize our conversation if we choose to move forward. Let's get started!

Ethical Disclaimer:
"This assessment is for informational purposes only and is not a substitute for medical advice, diagnosis, or treatment. I am not a licensed medical professional and do not prescribe or manage medications. If you have concerns about potential contraindications, please consult a qualified healthcare provider before proceeding.

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General Information
Name *
Age *
Gender *
Email *
Phone Number *
Occupation *
State you live in *

Are you curious about starting a microdosing protocol as a tool for personal growth, health, and well-being?"

 *

Have you tried microdosing before?

 *

What best describes your reason for exploring microdosing now? (Select all that apply)

 *
Required
Medical based questions
Please be as clear and specific as possible here to ensure proper evaluation
Do you currently work with any of the following? *
Required
Do any of the following situations pertain to you? 
🚫 Red Lights (Do Not Proceed)
 *
Required
Do any of the following situations pertain to you?
⚠️ Yellow Lights (Use caution / Individual Case-by-Case)
 *
Required
Do you currently struggle with any of the following
🟢 GREEN LIGHTS (Generally safe to proceed)
 *
Required
Have you ever been diagnosed with any other disease or condition that you would like to tell us about?
Are you currently taking ANY medications? *
Required
For medication: (Please list ANY and ALL of the medications you are taking, at what doses, at what intervals, and for why) or put NONE *
Are you looking to get off any of the above listed medications? *
Are you a female who is currently Pregnant or breastfeeding? *
Health, Wellness, and Lifestyle Section
This section will give us insights into your daily habits and choices. Allowing us to build a picture of your current starting point.
Have you recently taken a round of Antibiotics prescribed to you by your doctor? *
Required
Do you partake in any of these substances? *
Required
Please describe your usage with any of the above substances (How much, how often, if any, etc.) *
How would you rate your overall health and well-being? *
Terrible
Phenomenal
How would you rate your daily energy levels? *
Exhausted
Vibrant & Energized
How would you rate the quality of your sleep? (timing, duration, waking up energized, etc.)  *
Terrible
Phenomenal
How would you rate your overall quality of food choices and food habits?  *
Low Quality
High Quality
Do you currently follow a specific dietary approach? (Vegan, paleo, carnivore, balanced, intuitive, unrestricted, gluten free, etc.) *
Have you ever incorporated a Meditation Practice into your daily life? *
Do you exercise on a weekly basis? *
What would you say are your biggest health challenges right now? Or areas of focus needing major improvement right now? *
What would you like to accomplish with microdosing? *
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