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.

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* 1. Do You Find Your Body Gaining Weight Differently Through Menopause?

Yes

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* 2. Are You Unhappy Looking in the Mirror?

Yes

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* 3. With Menopause Is Body Image and Self Esteem a Concern?

Yes

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* 4. Have You Considered that Hormone Imbalance Could Be Causing Weight Gain?

Yes

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* 5. Did You Know That Hormones Could Be Spiking Your Blood Sugar?

Yes

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* 6. Are You Experiencing More Weight Gain In Your Tummy Area?

Yes

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* 7. Do You Think Cortisol Could Be a Cause of Weight Gain?

Yes

Unsure (please state why)

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* 8. Did You Know that Hormones Can be Stored in Fat Cells, Leading to High Estrogen and Hot Flashes?

Yes

Unsure (please state why)

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* 9. Did You Know That Cortisol Could Be Affecting Your Sleep Patterns?

Yes

Unsure (please state why)

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* 10. Do You Have a Low Libido?

Yes

If yes, is it related to self image, hormones or something else? Please comment.

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* 11. Have Your Sugar Cravings Increased with Menopause?

Yes

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* 12. With Menopause, Do You Find Your Clothes Fit Differently?

Yes

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* 13. Do You Wake Up In the Middle of the Night with Night Sweats?

Yes

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* 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

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* 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.

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