You Are One Step Closer To Feeling Like Yourself Again!

Please Fill Out The Survey Below.

Root Cause Survey

Congratulations on taking the next step in your health journey. Let's get to the root cause of your symptoms.

Full Name *

Phone *

Email *

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How old are you? *

Height *

Desired Weight *

Current Weight *

Current Rx Medicine (brand and dosage not critical, just what it is for, including HRT) *

On a scale of 1-10, how committed are you to eliminating your symptoms? ( 1 being "A little" and 10 being "I'm all in") *

On a scale of 1-10, what is your energy level? (1= totally fatigued 10=Energizer Bunny) *

Do you have a good support system for becoming healthy/eliminating symptoms and/or losing weight? If so, who? *

Have you been experiencing less motivation/zest for life? *

Yes

No

Have you been suffering from brain fog or has remembering things like names, words, where you put your phone or keys become more frequent? *

Yes

No

Have your mood swings become more erratic? Are you easily angered or irritated? *

Yes

No

Have you noticed that you cry more often? *

Yes

No

In the last 6 months, have you noticed that you are more anxious? *

Yes

No

Have you been experiencing inflammation like joint pain, muscle pain not due to exercise, stiff joints, trouble concentrating, frozen shoulder, more aches and pains than usual? *

Yes

No

How much alcohol do you consume per week? *

I don't drink or drink less than 2x a month

1-2 glasses/wk

3-4 glasses/wk

5+ glasses/week

Are you happy with your current profession or retirement? *

Yes

No

Are you experiencing sleep changes (ie. insomnia, wake up and can't go back to sleep, night sweats...) *

Yes

No

Do you recover less easily from exercise (worn out for a day or two)? *

Yes

No

Have you noticed you have begun to gain weight in your belly? *

Yes

No

What do you do for fitness? *

Has your doctor told you that you are at risk for cardiovascular disease? *

Yes

No

Has your doctor told you that you have increased risk of blood clots *

Yes

No

Do you have high blood pressure? *

Yes

No

Have your periods become less frequent or non-existent? *

Yes

No

Are you experiencing breast tenderness or changes in your breasts? *

Yes

No

Are you experiencing vaginal changes e.g. dryness, thinning skin, more pain during intercourse? *

Yes

No

Are. you experiencing urinary tract changes? *

Yes

No

Are you experiencing decreased libido? *

Yes

No

Is there anything else you would like to share? *

Thank you for taking our survey. Please click "Submit" so you can book a call with us, if you haven't already. We are looking forward to reviewing your results with you and strategizing so you can feel better.

As a disclaimer, this information is designed for educational and sharing

purposes, and you follow it at your own risk. I have done my

best to prepare an informative assessment, but

please speak with your physician before starting any fitness or nutrition

program, especially if you are at a higher risk for illness and

injury. Julie Powers and Online Weight Loss Solution and The

Momentum Maker assume no risk for your voluntary

participation.

We Look Forward To Strategizing With You.