Before we can welcome you as a new patient, the first step is this quick quiz.

This 5-minute quiz helps us understand your health concerns and see if our Whole Body Hormone Solution™ program is the right fit for you.

With the Whole Body Hormone Solution™ you'll get a personalized path to feeling like yourself again—using advanced testing, expert guidance, and whole-body therapies.

Step 1: This Quiz (5 minutes)

Share your symptoms and goals so we can understand where you are starting.

Step 2: The Clarity Protocol™

Advanced testing and diagnostics uncover the root cause of your hormonal imbalance.

Step 3: Reclaim™

We create your tailored treatment plan to effectively restore balance.

Your Details

First Name

Last Name *

Date of birth *

Email *

Phone *

Question 1:

1. How ready are you to commit to lasting transformation—not just short-term fixes?

Question 2:

2. This program involves follow-up visits, coaching sessions, and acupuncture/body treatments spaced over 6–8 months. Can you consistently commit time for these touchpoints?

Question 3:

What is your main health concern?

3.1.1 My biggest health concern is:

3.1.2. How Severe?

3.1.3. What have you tried?

3.1.4. Did it work?

Question 4:

4.1. How are your health concerns affecting your life?

My energy & ability to get things done

My mood & emotions (irritability, anxiety, depression)

My sleep & recovery

My weight & metabolism

My confidence in my body

My relationships with others

My ability to enjoy food without discomfort

Question 5:

5.1. Have you worked with other practitioners for this issue? If so, what was your experience?

5.2. What do you feel needs to happen for you to get better?

Question 6:

Check any that apply in the last 6-months or so.

6.1. Fatigue & Energy

I wake up feeling tired even after a full night’s sleep

I experience afternoon crashes or energy dips

I rely on caffeine or sugar to get through the day

I feel “wired but tired” at night

None

6.3. Hormones & Menstrual Health (If Applicable)

6.4. Skin & Inflammation

6.5. Do you have any other symptoms which are not listed?

Question 7:

Tell us about your Diet and Nutrition...

7.1.2. Other Special diet or food restrictions:

7.3. How many meals do you eat out per week?

0-1

1-3

3-5

Question 8:

Tell us about your lifestyle and stress levels...

8.1. How well are you sleeping?

I sleep through the night & wake up rested

I wake up 1-2 times but fall back asleep

I have trouble falling asleep

I wake up multiple times & feel exhausted in the morning

I sleep well

8.2. What’s your stress level on a scale of 1-10? (1 = No stress, 10 = Overwhelmed)

8.3. How does stress affect you? (Check all that apply)

Question 9:

Do you have any of the following medical conditions? (Check all that apply)

9.4. Other Conditions:

Anxiety / Depression

High Blood Pressure

Migraines

None

9.5. Do you have any other condition not listed?

Question 10:

10.1. Have you looked at the program pricing listed below?

Yes, I’ve reviewed it and understand the investment.

Yes, I've reviewed it, but I'm not prepared to invest in my health at this level yet

*This is a premium investment in your long-term vitality.

Part 1 – The Clarity Protocol – is $3,499 and includes advanced diagnostics, comprehensive testing, and your initial visits with our team.

Once this foundation is complete, you’ll have the option to continue into Part 2 – Reclaim™, our 6–8 month whole body transformation program, which delivers the specialized treatment protocols to help you feel like yourself again.

Question 11:

Tell us a bit about your Health Goals...

11.1. What do you hope to achieve from working with us?

11.2. When was the last time you felt truly well?

11.3. Did something specific trigger your health decline?

Would you like to get valuable insights about Gut and Hormone Health?

We can send you valuable insights, as well as actionable advice to help you better understand and manage your Gut and Hormone Symptoms. To get all this and more, all you need to do so sign-up to our newsletter, are you in?

Yes, I'm in! Please send me valuable insights to help me understand and manage my gut and hormone Health.

No, I'm not interested in receiving valuable insights that will help me understand and manage my gut and hormone health.

Next Steps:

What happens next?

1. You’ll receive an email with next steps and a video with our recommendations for you.

2. In the free recorded consultation we’ll go over:

✔ The root causes of your symptoms

✔ Where past approaches may have fallen short

✔ The best next steps to start feeling better

Consent & Disclaimer

Please read and agree to the following before proceeding:

I understand that completing this form is for informational purposes only, does not create a patient-physician relationship with Dr. Karolina Skrzypek or Natura Integrative & Functional Medicine, is not intended to diagnose, treat, or replace medical advice from my healthcare provider, and that any information I share will remain confidential and used solely for assessment and consultation.

Please confirm you agree to the above consent and disclaimer *

I agree to these terms.