Women's Hormonal Health & Weight Loss form

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From ovarian cysts, painful cycles, hormone imbalances, monthly bloat and weight gain what the heck is going on hormonally?

Your answers to the following questions will help guide my radio content and future wellness programs I offer. Thank you for your participation!

~Dr. Susan Plank

Do you suspect hormone imbalances? *

Yes

Not Sure

Are you or have you ever been on birth control pills for pain? *

Yes

Is or did your birth control helping with your pain? *

Yes

Does your weight vary more than five pounds monthly? *

Yes

Are you overweight, if so, by how much? *

<15 pounds

15-30 pounds

30-50 pounds

more than 50 pounds

Are you peri or post-menopausal? *

Yes

Not Sure

Do or did you experience PMS, period irregularity, monthly bloating and/or pain when you had your cycle? *

Yes

Sometimes

Have you had a hysterectomy due to your symptoms? *

Yes

Do you have low bone density? *

Yes

Not Sure

I am considering a multi-month program geared to identify and address hormone imbalances and weight, would you be interested? *

Yes

Maybe

If taking part in a hormone and weight loss wellness program, would you be interested in having your hormone levels tested?

Please rate this topic in the order of your interest:

Not Interested

Very Interested

Clear selection

If taking part in a hormone and weight loss wellness program would you be interested in being tested for food sensitivities that are contributing to weight gain and hormone imbalances?

Please rate this topic in the order of your interest:

Not Interested

Very Interested

Clear selection

If taking part in a hormone and weight loss program would you be interested in being tested for food sensitivities that are contributing to weight gain, cellular inflammation and resulting in hormone imbalances?

Please rate the topics in the order of your interest:

Not Interested

Very Interested

Clear selection

If taking part in a hormone and weight loss program would you be interested in participating in a group detoxification program to start losing weight and rebalancing hormones?

Please rate the topics in the order of your interest:

Not Interested

Very Interested

Clear selection

Would this type of informational, testing and action oriented group wellness program be of interest to you for two or three months at a fee of $297/ month?

Yes

Clear selection

If you would like further information or are interested in taking part in a hormone balancing and weight loss wellness program this fall please kindly supply your name and email address?

Would you like to be notified of Dr. Plank's upcoming webinars and programs? If so, please supply your name, email address and areas of interest?

Thank you for completing this survey for future radio content and wellness programs. I appreciate your time and input!~Dr. Susan Plank

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