Total Health and Wellness Makeover

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1. What is your contact information? (Required.)

Name: *

Address:

City/Town:

State:

ZIP:

Email Address: *

Phone Number: *

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2. What is your age? (Required.)

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3. What is your current height and weight? (Required.)

Height

Weight

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4. How motivated are you to put in the time and effort to look and feel your best? (Required.)

Not very motivated

Somewhat motivated

Motivated

Very motivated

Not very motivated

Somewhat motivated

Motivated

Very motivated

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5. Do you believe your current lifestyle: (Required.)

Positively affects your health

Negatively affects your health

Does not affect your health

Not Sure

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6. Of all the possible actions you could take in order to prevent disease and
maintain/enhance your health, how much do you estimate you are currently doing? (Required.)

0% (none at all)

25%

50%

75%

100% (all possible)

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7. Which area of behavior would you most like to change in order to improve your health? (Required.)

Exercise

Nutrition

Weight Management

Hormone Balance

Stress Management

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8. Are you familiar with natural hormone pellet replacement therapy? (Required.)

Yes, I currently receive this treatment

Yes, I have heard about it

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9. Do you have any of the following chronic illnesses? (Required.)

High cholesterol

Insulin resistance

High blood pressure

Type 2 Diabetes

Unhealthy body composition

PCOS

Chronic fatigue

Fibromyalgia

Obesity

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10. What treatments/medications are you currently using (i.e. Estrogen creams, testosterone shots, weight loss programs, anxiety medication)? (Required.)

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11. What symptoms ail you? (Required.)

Hot flashes

Weight gain

Fatigue

Anxiety

Low libido

Irritability

Depression

Trouble sleeping

Lack of mental clarity

Other (please specify)

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12. How do you feel about your current weight? (Required.)

Would like to lose weight

Would like to gain weight

Satisfied with weight

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13. Do you think your current level of stress is high enough to affect your health or quality
of life? (Required.)

Yes

Not sure

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14. How often do you feel a chronic sense of struggle with daily events? (Required.)

Never

Occasionally

Often

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15. Do your sleep patterns promote good health? (Required.)

Yes

Not sure

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16. What things would you most like to change about your appearance? (Required.)

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17. Have you previously received cosmetic injectable fillers? (Required.)

yes

Other (please specify)

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18. Have you had a lot of volume loss in your face? (Required.)

Yes

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19. What is your greatest skin concern on your face? (Required.)

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)

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20. Describe your skin: (Required.)

Oily

Dry

Combination

Acne prone

Rosacea

Other (please specify)

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21. Tell us which treatments or conditions are MOST important to you: (Required.)

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)

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22. How often do you wear sunscreen or protective clothing when you are in the sun? (Required.)

Never

Occasionally

Often

Always

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23. Do you take nutritional supplements? (Required.)

Yes

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24. What motivates you in life, family, work, health? (Required.)

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25. How do you think undergoing this makeover will affect your life? (Required.)

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26. Please tell us why you think we should select you for this makeover. (Required.)

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27. I understand the weekly appointment time commitment requirements of this makeover contest, especially for the first 3 months. (Required.)

Yes

Other (please specify)

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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? (Required.)

Yes

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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. (Required.)

YES, Proceed

NO, do not Proceed

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* 1. What is your contact information? (Required.)

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* 2. What is your age? (Required.)

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* 3. What is your current height and weight? (Required.)

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* 4. How motivated are you to put in the time and effort to look and feel your best? (Required.)

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* 5. Do you believe your current lifestyle: (Required.)

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* 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? (Required.)

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* 7. Which area of behavior would you most like to change in order to improve your health? (Required.)

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* 8. Are you familiar with natural hormone pellet replacement therapy? (Required.)

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* 9. Do you have any of the following chronic illnesses? (Required.)

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* 10. What treatments/medications are you currently using (i.e. Estrogen creams, testosterone shots, weight loss programs, anxiety medication)? (Required.)

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* 11. What symptoms ail you? (Required.)

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* 12. How do you feel about your current weight? (Required.)

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* 13. Do you think your current level of stress is high enough to affect your health or quality of life? (Required.)

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* 14. How often do you feel a chronic sense of struggle with daily events? (Required.)

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* 15. Do your sleep patterns promote good health? (Required.)

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* 16. What things would you most like to change about your appearance? (Required.)

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* 17. Have you previously received cosmetic injectable fillers? (Required.)

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* 18. Have you had a lot of volume loss in your face? (Required.)

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* 19. What is your greatest skin concern on your face? (Required.)

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* 20. Describe your skin: (Required.)

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* 21. Tell us which treatments or conditions are MOST important to you: (Required.)

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* 22. How often do you wear sunscreen or protective clothing when you are in the sun? (Required.)

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* 23. Do you take nutritional supplements? (Required.)

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* 24. What motivates you in life, family, work, health? (Required.)

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* 25. How do you think undergoing this makeover will affect your life? (Required.)

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* 26. Please tell us why you think we should select you for this makeover. (Required.)

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* 27. I understand the weekly appointment time commitment requirements of this makeover contest, especially for the first 3 months. (Required.)

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* 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? (Required.)

Question Title

1. What is your contact information? (Required.)

2. What is your age? (Required.)

3. What is your current height and weight? (Required.)

4. How motivated are you to put in the time and effort to look and feel your best? (Required.)

5. Do you believe your current lifestyle: (Required.)

6. Of all the possible actions you could take in order to prevent disease and
maintain/enhance your health, how much do you estimate you are currently doing? (Required.)

7. Which area of behavior would you most like to change in order to improve your health? (Required.)

8. Are you familiar with natural hormone pellet replacement therapy? (Required.)

9. Do you have any of the following chronic illnesses? (Required.)

10. What treatments/medications are you currently using (i.e. Estrogen creams, testosterone shots, weight loss programs, anxiety medication)? (Required.)

11. What symptoms ail you? (Required.)

12. How do you feel about your current weight? (Required.)

13. Do you think your current level of stress is high enough to affect your health or quality
of life? (Required.)

14. How often do you feel a chronic sense of struggle with daily events? (Required.)

15. Do your sleep patterns promote good health? (Required.)

16. What things would you most like to change about your appearance? (Required.)

17. Have you previously received cosmetic injectable fillers? (Required.)

18. Have you had a lot of volume loss in your face? (Required.)

19. What is your greatest skin concern on your face? (Required.)

20. Describe your skin: (Required.)

21. Tell us which treatments or conditions are MOST important to you: (Required.)

22. How often do you wear sunscreen or protective clothing when you are in the sun? (Required.)

23. Do you take nutritional supplements? (Required.)

24. What motivates you in life, family, work, health? (Required.)

25. How do you think undergoing this makeover will affect your life? (Required.)

26. Please tell us why you think we should select you for this makeover. (Required.)

27. I understand the weekly appointment time commitment requirements of this makeover contest, especially for the first 3 months. (Required.)

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? (Required.)