Weight Loss and Your Hormones Welcome To "Your Customized Weight Loss Program" Survey Thank you for taking the time to complete this survey. We will offer you a $50 off a Hormone Saliva Test. OK Question Title * 1. Do You Find Your Body Gaining Weight Differently Through Menopause? Yes No OK Question Title * 2. Are You Unhappy Looking in the Mirror? Yes No OK Question Title * 3. With Menopause Is Body Image and Self Esteem a Concern? Yes No OK Question Title * 4. Have You Considered that Hormone Imbalance Could Be Causing Weight Gain? Yes No OK Question Title * 5. Did You Know That Hormones Could Be Spiking Your Blood Sugar? Yes No OK Question Title * 6. Are You Experiencing More Weight Gain In Your Tummy Area? Yes No OK Question Title * 7. Do You Think Cortisol Could Be a Cause of Weight Gain? Yes No Unsure (please state why) OK Question Title * 8. Did You Know that Hormones Can be Stored in Fat Cells, Leading to High Estrogen and Hot Flashes? Yes No Unsure (please state why) OK Question Title * 9. Did You Know That Cortisol Could Be Affecting Your Sleep Patterns? Yes No Unsure (please state why) OK Question Title * 10. Do You Have a Low Libido? Yes No If yes, is it related to self image, hormones or something else? Please comment. OK Question Title * 11. Have Your Sugar Cravings Increased with Menopause? Yes No OK Question Title * 12. With Menopause, Do You Find Your Clothes Fit Differently? Yes No OK Question Title * 13. Do You Wake Up In the Middle of the Night with Night Sweats? Yes No OK Question Title * 14. How Happy Are You With This Stage of Your Life? 1 2 3 4 5 Happiness Level (5 being highest) Happiness Level (5 being highest) 1 Happiness Level (5 being highest) 2 Happiness Level (5 being highest) 3 Happiness Level (5 being highest) 4 Happiness Level (5 being highest) 5 OK Question Title * 15. Thank You for Completing Our Survey. In appreciation for your time, we would like to offer you $50 off our Hormone Saliva Test. Please complete all fields in this form to receive our special offer. Name Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number OK DONE
