Wellness Planning Tool
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*
" indicates required fields
Step
1
of
10
10%
Are you male or female?
*
Male
Female
Have you experienced any of the following symptoms in the last 3 months?
*
Select all that apply.
Joint Pain
Fatigue
Low Libido
Weight Gain
Brain Fog
Night Sweats
Mood Changes
Depression
Anxiety
Menstrual Changes
Hair Loss
How much weight would you need to lose to achieve your ideal weight?
*
Less than 15 pounds
More than 15 pounds
Have you experienced any of the following genitourinary symptoms?
*
Select all that apply.
Vaginal Atrophy
Vaginal Dryness
Painful Intercourse
Urinary Incontinence
Frequent Urination
None
Have you struggled with any of the following gastrointestinal symptoms:
*
Select all that apply.
Bloating
Gas
Constipation
Diarrhea / Loose Stools
Abdominal Discomfort with Meals
None
Do you believe your chronological age (the number on your driver's license) matches your biological age (how you look/feel)?
*
Yes, I look/feel my age
No, I look/feel older than my age
How many vitamins or supplements do you take on a daily basis?
None
1-4
5+
Have you ever tried to “reset” your body’s overall health through a gut or liver detox program?
*
Yes
No
How would you like to be contacted?
*
Call
Text
Email
All
Let us know how to get in touch to discuss your results.
First Name
*
Last Name
*
Phone
*
Email
Outreach Acknowledgement
*
By clicking “Submit”, I acknowledge that Beauty Culture Spa will use the information above to contact me through phone, email, and/or text.
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UTM Source