Hormone Blance ♀️♂️
Complete this form so we can assess your hormones, lifestyle, and goals. Only answer the questions that apply to you.:
Name:
*
Surname:
*
Phone:
*
Email:
*
Confirm Email:
*
Age:
*
Sex:
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Female
Male
Height (cm):
Weight (kg):
What are your main goals? (select all that apply):
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Fat loss
Muscle gain
Improve energy
Improve libido
Hormone balance
Fix low testosterone
Improve mood / mental clarity
Performance / training
Are you currently experiencing any of these symptoms?:
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Low energy / fatigue
Low libido
Brain fog
Poor sleep
Mood swings / anxiety
Stubborn fat gain
Difficulty building muscle
Low motivation
Irregular periods
Painful periods
Hormonal acne
Bloating / water retention
Hot flushes / menopause symptoms
Have you ever had bloodwork done?:
Yes
No
Have you ever used performance enhancing drugs (PEDs) or hormones?:
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No
Yes (previously)
Yes (currently)
♀️Female Hormone Health (skip if not applicable):
♀️Have you been diagnosed with any of the following?:
PCOS
Endometriosis
Menopause
None
♀️How would you describe your cycle?:
Regular
Irregular
Not applicable
♂️Male Hormone Health (skip if not applicable):
Have you experienced any of the following?:
Low testosterone diagnosis
Low libido
Erectile dysfunction
Poor recovery
Difficulty building muscle
None
How many days per week do you train?:
0
1-2
3-4
5+
How many hours do you sleep per night?:
Less than 5
5-6
6-7
7+
Current stress levels:
Low
Moderate
High
What supplements or medications are you currently taking?:
What’s your biggest frustration with your body or hormones right now?:
*
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