Kult - Comprehensive Supplement Assessment

The following sections appear based on age and gender combination

This section appears for males aged 18-30

Young Adult Male Health Conditional - Male 18-30

Common concerns for young men: (Check all that apply)

Muscle building/gym performance

Work/career stress

High energy drink consumption

Irregular meal patterns

Frequent late nights/poor sleep

This section appears for females aged 18-30

Young Adult Female Health Conditional - Female 18-30

Common concerns for young women: (Check all that apply)

Birth control side effects

PCOS symptoms

Heavy/painful periods

Acne/skin issues

Fertility planning

This section appears for males aged 31-45

Middle Adult Male Health Conditional - Male 31-45

Health concerns for men 31-45: (Check all that apply)

Low energy/testosterone concerns

Weight gain/metabolism slowing

Work-life balance stress

Early heart health concerns

Slower recovery from exercise

This section appears for females aged 31-45

Middle Adult Female Health Conditional - Female 31-45

Health concerns for women 31-45: (Check all that apply)

Post-pregnancy recovery

Hormone fluctuations

Thyroid concerns

Mom fatigue/burnout

Early perimenopause signs

This section appears for males aged 46-60

Mature Male Health Conditional - Male 46-60

Health priorities for men 46-60: (Check all that apply)

Prostate health

Cardiovascular risk management

Joint stiffness/arthritis

Maintaining mental sharpness

Sexual health concerns

This section appears for females aged 46-60

Mature Female Health Conditional - Female 46-60

Menopause and midlife concerns: (Check all that apply)

Hot flashes/night sweats

Menopause weight gain

Bone density concerns

Mood changes/anxiety

Vaginal dryness/discomfort

Are you on hormone replacement therapy (HRT)?

Yes

Considering it

This section appears for males aged 60+

Senior Male Health Conditional - Male 60+

Senior health priorities: (Check all that apply)

Maintaining muscle mass

Balance and fall prevention

Memory support

Multiple medication management

Prostate health management

This section appears for females aged 60+

Senior Female Health Conditional - Female 60+

Senior women's health priorities: (Check all that apply)

Osteoporosis prevention/management

Balance and fall prevention

Cognitive health

Heart health (post-menopause risk)

Social isolation/mood

Section 2: Medical History

Current Medical Conditions

Diabetes Information Conditional

What type of diabetes?

Type 1

Type 2

Most recent A1C level (if known)

Thyroid Information Conditional

Please specify your thyroid condition and current medications

Medical History

Does anyone in your immediate family have chronic health conditions?

No family history

Yes - Diabetes

Yes - Heart disease

Yes - Thyroid disorders

Yes - Autoimmune conditions

Yes - Other:

Have you had any surgeries that might affect nutrient absorption?

No surgeries

Gastric bypass/Weight loss surgery

Gallbladder removal

Bowel/Intestinal surgery

Hysterectomy

Other:

Section 3: Current Symptoms

Energy & Fatigue

Low Energy Details Conditional

When is your energy the lowest?

Morning - Hard to wake up

Mid-morning crash

After lunch crash

Late afternoon

Evening fatigue

All day fatigue

Sleep Quality

Sleep Issues Conditional

What sleep issues do you experience?

Difficulty falling asleep

Wake up multiple times

Wake up too early

Don't feel rested

Snoring/Sleep apnea

Restless legs

Night sweats

Do you have good sleep habits?

Sleep in a dark room

Keep bedroom cool (65-68°F)

Avoid screens 1 hour before bed

Have a consistent sleep schedule

Avoid caffeine after 2 PM

Have a relaxing bedtime routine

Symptom Assessment

Other symptoms (Check all that apply)

Hair loss/thinning

Brittle nails

Dry skin

Cold hands/feet

Slow wound healing

Frequent infections

Section 4: Medications & Supplements (Critical Section)

Current Medications

Are you currently taking any prescription medications?

No medications

Yes (please list below)

Medication List Conditional

Current Supplements

Are you currently taking any supplements?

No supplements

Yes (please list below)

Supplement List Conditional

Section 5: Diet & Lifestyle

Diet

Primary diet type:

Omnivore

Vegetarian

Vegan

Low-carb/Keto

Intermittent Fasting

Other:

Food restrictions/allergies: (Check all that apply)

None

Gluten-free

Dairy-free

Nut allergy

Soy-free

Egg-free

Other:

Hydration & Habits

Physical Activity

Athletic Performance Conditional

Training hours per week:

Primary sport/activity:

Competition level:

Recreational

Amateur competitive

Professional

Performance goals:

Increase endurance

Build strength

Improve recovery

Enhance performance

Recovery challenges:

Muscle soreness

Fatigue

Joint pain

Slow recovery

Other Lifestyle Factors

Section 6: Women's Health Conditional - Female Only

Menstrual status:

Regular periods

Irregular periods

No periods

Perimenopause

Menopause

Post-menopause

Average cycle length:

Less than 21 days

21-35 days

More than 35 days

Varies significantly

Period flow:

Light

Moderate

Heavy

Very heavy

Menstrual symptoms: (Check all that apply)

Severe cramps

Heavy bleeding

PMS/PMDD

Menstrual migraines

Significant mood changes

Pregnancy/Breastfeeding status:

Not applicable

Trying to conceive

Currently pregnant

Currently breastfeeding

Section 7: Health Goals

What are your top 3 health goals?

Energy Goals Conditional

When do you need energy most?

Morning start

Midday boost

Afternoon slump

All-day sustained energy

What currently helps your energy?

Coffee/caffeine

Short naps

Exercise

Eating regularly

Nothing really helps

How dependent are you on caffeine?

Not at all

Somewhat - can function without

Very - need it to function

Trying to reduce dependence

Sleep Goals Conditional

What's your biggest sleep challenge?

Can't fall asleep

Can't stay asleep

Wake too early

Never feel rested

What have you tried for sleep?

Melatonin

Magnesium

Sleep hygiene changes

Prescription sleep aids

Nothing yet

Weight Management Goals Conditional

Primary weight challenge:

Can't lose weight

Can't gain weight

Weight fluctuates

Slow metabolism

Eating patterns:

Emotional eating

Late night snacking

Skip meals

Constant hunger

No appetite

Previous weight management attempts:

Digestion Goals Conditional

What's your main digestive concern?

Bloating and gas

Irregular bowel movements

Acid reflux/heartburn

Food sensitivities

When do digestive issues occur?

Immediately after meals

First thing in morning

Evening/night time

During stressful periods

Random/unpredictable

What have you tried for digestive health?

Probiotics

Digestive enzymes

Elimination diet

Fiber supplements

Nothing yet

Section 8: Additional Information

Is there anything else about your health that would help us personalize your recommendations?

Symptom	0	1	2	3	4	5
Anxiety
Depression
Brain fog
Memory issues
Mood swings

Symptom	0	1	2	3	4	5
Headaches/Migraines
Joint pain
Muscle weakness/cramps
Numbness/Tingling
Dizziness
Low libido/sex drive

Symptom	0	1	2	3	4	5
Bloating
Gas
Constipation
Diarrhea
Acid reflux

Comprehensive Supplement Assessment

Section 1: Basic Information

Young Adult Male Health Conditional - Male 18-30

Young Adult Female Health Conditional - Female 18-30

Middle Adult Male Health Conditional - Male 31-45

Middle Adult Female Health Conditional - Female 31-45

Mature Male Health Conditional - Male 46-60

Mature Female Health Conditional - Female 46-60

Senior Male Health Conditional - Male 60+

Senior Female Health Conditional - Female 60+

Section 2: Medical History

Current Medical Conditions

Diabetes Information Conditional

Thyroid Information Conditional

Medical History

Section 3: Current Symptoms

Energy & Fatigue

Low Energy Details Conditional

Sleep Quality

Sleep Issues Conditional

Symptom Assessment

Digestive Symptoms

Mental/Cognitive Symptoms

Physical Symptoms

Section 4: Medications & Supplements (Critical Section)

Current Medications

Medication List Conditional

Current Supplements

Supplement List Conditional

Section 5: Diet & Lifestyle

Diet

Hydration & Habits

Physical Activity

Athletic Performance Conditional

Other Lifestyle Factors

Section 6: Women's Health Conditional - Female Only

Section 7: Health Goals

What are your top 3 health goals?

Energy Goals Conditional

Sleep Goals Conditional

Weight Management Goals Conditional

Digestion Goals Conditional

Section 8: Additional Information

Section 9: Consent