Please take a few moments to complete our brief questionnaire to identify your weight loss goals and determine if one of our weight loss programs may be the answer you've been looking for.
First Name
*
Date of Birth
*
Sex/Gender
*
Female
Male
Phone
*
Email
*
Current Weight (lbs.)
Target Weight
Have you tried restrictive diets with the following results? (Choose all that apply)
Limited to no results
Unable to stick to dietary restrictions
Took too long to see results
I regained all of the weight (or more) soon after quitting the diet
ALL OF THE ABOVE
With respect to my appetite: (Choose all that apply)
I have trouble controlling my appetite
I often crave unhealthy foods
I am an emotional eater (e.g., I eat when I'm upset, depressed, angry, bored)
ALL OF THE ABOVE
Have you considered or tried exercise programs with the following results? (Choose all that apply)
Wasn't able to lose the amount of weight I wanted to
Wasn't able to lose fat in stubborn areas
It took too much time to lose the weight I wanted to lose
I regained all of the weight (or more) soon after quitting the exercise program
ALL OF THE ABOVE
Often, excess weight can be related to hormone imbalances. The following questions will determine if you may also be suffering from a natural hormone deficiency.
Do you suffer from sleep disturbances, chronic fatigue, or decreased energy levels?
Yes
No
Do you more frequently feel anxious, irritable, or depressed?
Yes
No
Have you suffered from decreased physical strength, loss of muscle tone and/or joint pain?
Yes
No
Have you noticed a decrease in your skin's radiance, elasticity, and/or thickness?
Yes
No
Are you experiencing a loss of libido (either decreased sex drive and/or issues with sexual arousal)?
Yes
No
Are you having issues with hot flashes, night sweats, and/or vaginal dryness?
Yes
No
N/A
If you answered 'YES' to any of the above, you may be suffering from a hormonal deficiency which can be easily addressed through our natural, bio-identical hormone replacement therapy.
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