First Name
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State you live in?
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Michigan
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What’s your age range?
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Under 40
40–49
50–59
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What service are you interested in?
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Functional Medicine
Medical Weight Loss
Hormone Replacement Therapy
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9am-12pm
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What kind of support are you looking for with functional medicine? Select all that apply
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Gut health
Thyroid balance
Hormone imbalance
Chronic fatigue
Sleep or stress issues
Blood sugar issues
Other
What is your current weight and your weight goal?
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Have you tried any other programs, medications, or diets before? (Yes/no and explain what hasn't worked)
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Are you open to FDA-approved medication options (e.g., tirzepatide, semaglutide, others)?
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Yes
No
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What symptoms are you currently experiencing? (check all that apply)
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Fatigue
Mood changes or irritability
Irregular or missed periods
Hot flashes or night sweats
Low libido or vaginal dryness
Sleep disruptions
Irregular periods
Other
Are you currently using or have you previously used any hormone-related treatments (e.g., birth control, thyroid meds, bioidentical hormones)? If so, please specify which one and if not leave blank.
How did you hear about us?
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