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Balance Your Hormones 101 Sign Up Form- June Cohort
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Full Name
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Email address
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Phone Number
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Location
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Occupation
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Your answer
In a few sentences, please describe why you're interested in taking this course
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Your answer
Which one of these sentences best describes you?
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I am looking to make a major change in my diet and lifestyle in order to balance my hormones and work towards greater health
I am interested in learning more about my hormonal health but I'm not sure if I'm ready to make any actual changes in my diet or lifestyle.
Are you able to attend the live sessions on June 13th, June 20th, June 27th, July 4th?
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Yes
No
Not sure yet
The next set of questions asks about your personal health history. You don't have to answer any of these, but if you do I can make sure to tailor relevant nutritional information to those issues throughout the course. All answers are confidential.
Fibroids
PMS
PMDD
Ovarian Cysts
Irregular periods
Endometriosis
Fatigue/Exhaustion
Insomnia
Hypothyroidism
Hyperthyroidism
Anxiety
Depression
Weight gain or difficulty losing weight
PCOS
Mood Swings
Headaches
Migraines
Are you currently on birth control?
yes
no
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Which of the following topics are of interest to you?
fertility- optimizing your chances of conceiving
understanding your cycle- what happens hormonally in a woman's menstrual cycle
chronic disease and nutrition- how food can feed disease or fuel our health
the science behind weight loss and maintaining weight loss
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