LYSP Application Form

The Love Your Skin Program Application Form

The questionnaire must be filled out prior to booking your FREE Eczema Clarity call to workshop what’s been keeping you stuck and how to start healing your eczema.
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Full Name*
Email*
Phone Number*
Phone Number*
Please include your country code (example: +1 for North America, +61 for Australia)
Please select the age range of the person with eczema:*

0 - 17 years18 - 23 years24 years and aboveThis is NOT me, I am filling this out for family or a friend.
On a scale of 1 - 10, how have your eczema symptoms been these past few months?*

1

2

3

4

5

6

7

8

9

10

1 is Minimal, 10 is Severe
What symptoms are you currently experiencing?*

RednessItchingDrynessFlakingDandruffBloatingCramping/PainRefluxGasStressAnxietyFatigueHeadacheBreast Tenderness (Women)Back/Pelvic Pain (Women)Moodiness (Women)Heavy Flow (Women)Blood Clotting (Women)Cyclic Acne (Women)Difficulty SleepingPoor Quality SleepAsthmaAllergiesHay FeverInfectionsOther
What are you CURRENTLY working on to try to heal your skin and/or any other health conditions? (Diet/lifestyle, medications, creams/lotions, alternative therapies, etc.)*
Are you CURRENTLY using topical steroids (or any other form of steroid)?*

YesNo, I stopped taking them *LESS THAN* 6 months agoNo, I stopped using them *OVER* 6 months agoNo, I've never used steroids
Are you currently pregnant or breastfeeding?

PregnantBreastfeedingBothNeither
What’s happening in your life now that has you potentially considering making changes to address your health and heal your flare ups? (Please be as detailed as possible)*
Are you committed to intentionally taking action and creating the results that you want?*

Yes, I'm done being stuck and ready to financially invest in myself to heal my skin once and for allNo I can’t invest at all
On the next page, you will be invited to book a FREE call with our Eczema Clarity Coach. We ask you to respect the team's time and only book a call if you are 100% committed and serious about this call.
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The Love Your Skin Program Application Form