Free Hormone Imbalance Quiz

1

Sex* This field is required.

Male

Female

2

What would you like to explore?* This field is required.

Hormone Imbalance

Weight Management

3

Have you noticed a decreased enjoyment of life?* This field is required.

Yes

No

4

Have you noticed muscle loss?* This field is required.

Yes

No

5

Have you noticed muscle loss?* This field is required.

Yes

No

6

Do you have a lack of energy, or have your energy levels decreased?* This field is required.

Yes

No

7

Are you falling asleep after dinner?* This field is required.

Yes

No

8

Do you have restless sleep or sleep disturbances?* This field is required.

Yes

No

9

Do you have difficulty concentrating, or have short-term memory loss?* This field is required.

Yes

No

10

Are you moody or easily irritated?* This field is required.

Yes

No

11

Do you have hot flashes?* This field is required.

Yes

No

12

Have you experienced low libido and/or pain during intercourse?* This field is required.

Yes

No

13

Are you sad and or grumpy?* This field is required.

Yes

No

14

Has there been a recent deterioration in * This field is required.

Yes

No

15

Have you lost height?* This field is required.

Yes

No

16

Have you noticed a recent deterioration* This field is required.

Yes

No

17

Are your erections less strong?* This field is required.

Yes

No

18

Do you have excess body fat?* This field is required.

Yes

No

19

Do you want to lose weight?* This field is required.

Yes

No

Unsure

20

Why do you want to lose weight?* This field is required.

Improve Overall Health

Boost Your Confidence

Fit Clothes Better

All Of The Above

21

How much weight do you want to lose?* This field is required.

Less than 20 lbs

20-45 lbs

46 and up

Unsure

22

Which weight loss medications are you interested in?* This field is required.

GLP-1 Injections

Oral Medications, No Injections

Oral Medications and Injections

Unsure

23

What is your level of commitment to lose weight?* This field is required.

Lets get started today

My health is failing, I need help!

Still considering my options

Unsure

24

Type a question* This field is required.

First Name

Last Name

Email Address

Phone number

How Did You Hear About Us?

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25

Please verify that you are human* This field is required.

26

Thank you for completing the quiz.

Your results will be reviewed, and we will contact you soon to explore your symptoms and provide the next steps for diagnosis. In the meantime, check out our resources to learn more about how Emerge & Bloom Wellness LLC can help you.

This quiz is designed to provide guidance and is not intended to be medical advice. Blood testing and consulting with Emerge & Bloom Wellness LLC are required to diagnose hormone imbalances and begin a replacement protocol.

If you are having an emergency, please contact 911.