Womens questionaire

First name

Last name

Email

Phone

Birthday

Month

Day

Year

What are your main health goals? (Check all that apply)

Are you experiencing hair thinning/loss? If Yes, how long?

What skin concerns do you have? (acne, wrinkles, dullness, sun damage, etc.)

Do you have any concerns about your sexual health or function? (Yes/No)

Yes

No

Do you have issues with energy levels, mood, or motivation?

Do you experience chronic pain or inflammation anywhere in your body? (Yes/No) If yes, for how long and where?

How soon are you looking to start a weight loss program?

Immediately

Within 1 month

Just researching for now

Do you have any current injuries that aren't healing properly? (Yes/No If yes, explain.

Which best describes your body shape or where you tend to carry weight? (Check all that apply)

How much weight would you like to lose?

0–10 lbs

10–20 lbs

20–40 lbs

40+ lbs

How would you describe your current fitness level?

What type of workouts do you typically do? (Check all that apply)

Do you follow a specific diet or nutrition plan?

No

Yes

Have you tried any of the following in the past? (Check all that apply)

How committed are you to making lifestyle changes? (1-10 scale)

What is your budget range for wellness treatments per month?

How did you hear about our services, and what attracted you to peptide/wellness therapy?