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VIP Application

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Question 1 of 13

What is your name?

Question 2 of 13

What is your email address?

Question 3 of 13

What is your phone number?

Question 4 of 13

What are the main hormone related challenges you are currently experiencing?

(Select all that apply)
A

Hair issues (loss of scalp hair, slow growth, increased body/facial hair)

B

Skin Concerns (dry skin, acne etc)

C

Low libido or changes in sexual drive

D

Mood swings, irritability or anxiety

E

irregular menstrual cycles

F

Persistent fatigue or low energy

G

Difficulty losing weight or unexplained weight gain

H

Sleep Issues (difficulty falling sleep, staying asleep or waking unrefreshed)

I

Brain fog or difficulty focusing

J

Digestive Issues (bloating, constipation etc)

K

Infertility

L

Hot flashes or night sweats

M

None

Question 5 of 13

What have you already tried to address these issues?

(Select all that apply)
A

Traditional Medicine (hormonal birth control, thyroid medication etc)

B

Over the counter supplements or herbs

C

Specific Diets (keto, paleo, intermittent fasting etc)

D

Exercise programs or personal training

E

Holistic or alternative therapies (e.g., acupuncture, chiropractic care, etc.)

F

Hormone replacement therapy (HRT)

G

Stress management practices (e.g., meditation, yoga, etc.)

H

Lifestyle changes (e.g., sleep hygiene, reducing toxins, etc.)

I

None of the above

Question 6 of 13

How long have you been dealing with these symptoms?

A

Less than 6 months

B

6 months to 1 year

C

1-2 years

D

3+ years

Question 7 of 13

What are your biggest health goals right now?

(Select all that apply)
A

Restoring energy and vitality

B

Achieving sustainable weight loss

C

Regulating my menstrual cycle

D

Optimizing fertility

E

Stabilizing my mood and emotions

F

Improving libido and sexual health

G

Sleeping better and waking up refreshed

H

Feeling in control of my body and health

I

Healing naturally without dependence on medications

Question 8 of 13

How do these symptoms affect your daily life?

(Select all that apply)
A

I feel constantly exhausted

B

I struggle to keep up with my kids/family

C

My relationships are impacted due to mood swings or low libido

D

I've lost confidence in my body and health

E

My work or productivity is suffering due to fatigue or brain fog

F

I don't feel like myself anymore

Question 9 of 13

What are you struggling with most right now?

Question 10 of 13

If you could see one major shift over the next 6 months what change would make you happiest?

Question 11 of 13

Have you worked with a Functional Medicine Practitioner or Health Coach before? If so, what was your experience like?

Question 12 of 13

Are you ready and able to make the investment required to join the program? 

A

Yes, please send me the link to register!

B

Yes, I’m ready to invest in my health – I just have a few questions & would love a phone call

C

I’m interested but still exploring my options

D

Not quite yet - I'm just curious

Question 13 of 13

Is there anything else you feel I should know?

Confirm and Submit