Exit this survey Total Health and Wellness Makeover Question Title * 1. What is your contact information? Name: * Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: * Phone Number: * Question Title * 2. What is your age? Question Title * 3. What is your current height and weight? Height Weight Question Title * 4. How motivated are you to put in the time and effort to look and feel your best? Not very motivated Somewhat motivated Motivated Very motivated Not very motivated Somewhat motivated Motivated Very motivated Question Title * 5. Do you believe your current lifestyle: Positively affects your health Negatively affects your health Does not affect your health Not Sure Question Title * 6. Of all the possible actions you could take in order to prevent disease andmaintain/enhance your health, how much do you estimate you are currently doing? 0% (none at all) 25% 50% 75% 100% (all possible) Question Title * 7. Which area of behavior would you most like to change in order to improve your health? Exercise Nutrition Weight Management Hormone Balance Stress Management Question Title * 8. Are you familiar with natural hormone pellet replacement therapy? Yes, I currently receive this treatment Yes, I have heard about it No Question Title * 9. Do you have any of the following chronic illnesses? High cholesterol Insulin resistance High blood pressure Type 2 Diabetes Unhealthy body composition PCOS Chronic fatigue Fibromyalgia Obesity Question Title * 10. What treatments/medications are you currently using (i.e. Estrogen creams, testosterone shots, weight loss programs, anxiety medication)? Question Title * 11. What symptoms ail you? Hot flashes Weight gain Fatigue Anxiety Low libido Irritability Depression Trouble sleeping Lack of mental clarity Other (please specify) Question Title * 12. How do you feel about your current weight? Would like to lose weight Would like to gain weight Satisfied with weight Question Title * 13. Do you think your current level of stress is high enough to affect your health or quality of life? Yes No Not sure Question Title * 14. How often do you feel a chronic sense of struggle with daily events? Never Occasionally Often Question Title * 15. Do your sleep patterns promote good health? Yes No Not sure Question Title * 16. What things would you most like to change about your appearance? Question Title * 17. Have you previously received cosmetic injectable fillers? yes no Other (please specify) Question Title * 18. Have you had a lot of volume loss in your face? Yes No Question Title * 19. What is your greatest skin concern on your face? Fine lines and wrinkles Deep lines and wrinkles Crows feet Saggy facial skin Corners of mouth turn down No volume in lips Other (please specify) Question Title * 20. Describe your skin: Oily Dry Combination Acne prone Rosacea Other (please specify) Question Title * 21. Tell us which treatments or conditions are MOST important to you: Permanent hair removal Non-surgical liquid & laser facelift Acne scarring Removal of: facial veins, rosacea, sun damage, freckles, hyperpigmentation or discoloration Botox, Dysport and Filler treatment options A specific skin issue not listed Fat reduction and cellulite treatments Skin tightening on face or body I'm simply fed up with wrinkles, saggy skin and cellulite, and want to take years off! Other (please specify) Question Title * 22. How often do you wear sunscreen or protective clothing when you are in the sun? Never Occasionally Often Always Question Title * 23. Do you take nutritional supplements? Yes No Question Title * 24. What motivates you in life, family, work, health? Question Title * 25. How do you think undergoing this makeover will affect your life? Question Title * 26. Please tell us why you think we should select you for this makeover. Question Title * 27. I understand the weekly appointment time commitment requirements of this makeover contest, especially for the first 3 months. Yes No Other (please specify) Question Title * 28. Do you understand that to complete your contest registration, you will need to email a current, full body photo and contact information to rsvp@hormonalhealthandwellness.com? Yes No Question Title * 29. If chosen, I understand a $1,500 deposit is required. In the event that participant decides, for any reason, not to continue, the deposit is non-refundable. Deposit is refundable upon three stages of completion of program. $750 is refunded after completion of 3 month of program, and $750 is refunded after 6 months completion. YES, Proceed NO, do not Proceed Done
