Reset - ProDietitians

Name

Phone Number

Date of Birth

Address

What are your primary health goals for joining this program. The more detail you provide, the better we can help.

Select all that apply

Reduce PMS symptoms (pain, cramps, backache, breast tenderness, mood swings, fatigue, acne, bloating) Regulate my cycle (no more skipping periods or irregular cycles) Be in tune with my body and my fluctuating hormones Improve energy levels Address menopause or perimenopause symptoms (hot flashes, night sweats, irregular cycle, increased anxiety, insomnia, vaginal dryness, hair thinning) Improve libido Improve sleep quality Manage weight Manage brain fog or difficulty concentrating

What have you tried in the past to address your hormonal concerns?

Are you currently taking any medications, supplements, or hormone replacement therapy?

Do you have any diagnosed medical conditions?

Have you undergone any hormone testing in the past?

Do you have any known allergies or dietary restrictions?

Which program are you applying for?

3-Month Hormonal Reset Program ($1800) DUTCH Test + 1 Private Consultation ($980)

The Hormonal Reset Program requires active participation in private and group sessions. Are you able to dedicate time and energy to this process?

Yes No

Are you committed to making changes to your diet, lifestyle, and supplement routine if recommended?

Yes No

Is there anything else you'd like us to know about your health journey or reasons for joining the program?

Hormonal Reset Program 2024

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