Hormone Assessment Form Step 1 of 9 11% NameThis field is for validation purposes and should be left unchanged.How old are you?Under 3030-4041-50Over 50 Do you have weight to lose?Yes, 15-20Yes, 30-40 poundsYes, more than 40 poundsNo, I am happy with my weight What have you done in the past to lose weight?Diet and exerciseMedically assisted weight loss (surgery, injections and/or drugs)Weight loss program such as Weight Watchers or NoomI never had to lose weight What is your motivation to lose weight?I want to feel healthierI want to improve my quality of lifeI want to fit in my clothes againI have a special event coming upOther Check any of the hormonal symptoms that you have been experiencing that relate to high or low cortisol levels. Weight gain, stubborn fat around belly, hips, butt area Exhausted from running task to task; fatigued; experiencing afternoon crashes Difficulty falling asleep and/or staying asleep Irritability/ Anxiety Heart palpiltations Digestive issues such as bloating, constipation, IBS Check any of the hormonal symptoms that you have been experiencing that relate to high or low estrogen levels. Weight gain, stubborn fat around belly, hips, butt area Hot flashes, night sweats, PMS Mood swings, irritability, anxiety, depression Brain fog, difficulty concentrating Vaginal dryness, low libido, painful intercourse Thinning skin and hair Breast or ovarian cysts, fibroids, Endometriosis, painful periods Fluid retention, puffiness Check any of the hormonal symptoms that you have been experiencing that relate to insulin or blood sugar issues Unexplained weight gain; difficulty losing weight; stubborn belly fat Sweet and salty cravings Fatigued, feeling tired especially after eating Moody and impatient Increased thirst Shakey, nervous or anxious, difficulty concentration, lightheadedness On a scale of 1-10, how would you feel if you could lose weight AND alleviate these hormonal symptoms? Almost there, add your information for your results!Name(Required) First Last Email(Required) Phone Button
