Hair Talk Quiz Form

Full Name*
Email*
example@example.com
Mobile Number*

Area CodePhone Number
What is your age range?*

18-2425-3434-4445-5455+
Are you experiencing any of the following?*

Stubborn WeightBloating/Gut IssuesHormonal ImbalancesHair LossLow-EnergyFatigue
Have you been diagnosed with any type of disease? If so, what type?*
What treatments or products have you tried in the past?*
Do you have any diagnosed health conditions?*

PCOSMenopauseThyroid IssuesPre-DiabetesInsulin Resistance
How does this make you feel? please explain.*
Are you currently on any medications or supplements?*
What does your typical weight loss diet look like?*

Balanced with fruits, vegetables, and proteinsHigh in processed foods or sugarVegan/VegetarianKeto DietFruit Diet
Do you experience any of the following?*

FatigueDigestive IssuesHormonal Mood SwingsStubborn Belly FatInflammationBloatingThinning/Shedding
What are your primary goals?*

Lose 10-20 lbsBalance HormonesReduce BloatingGrow thicker hair
Do you have any specific questions or concerns?*
If you could wave a magic wand, how would you solve your frustrations?*
How did you find us?*

InstagramTiktokYoutubeFacebook
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