PCOS Metabolic Rebuild 1:1 Application
This application is for women with PCOS who are ready for a structured, metabolism-focused approach to sustainable fat loss, hormone balance, and long-term health. Please answer honestly so we can determine if this program is the right fit.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Age
*
Location (City and State)
*
Best way to contact you:
*
Email
Facebook Messenger
Have you been formally diagnosed with PCOS by a healthcare professional?
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Yes
No, but I strongly suspect I have it
I’m currently being evaluated
At what age were you diagnosed or when did symptoms begin?
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Which PCOS symptoms do you currently experience? (Select all that apply)
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Weight gain or difficulty losing weight
Irregular or missing cycles
Insulin resistance or blood sugar issues
Cravings or intense hunger
Fatigue or low energy
Acne
Excess facial or body hair
Hair thinning
Mood swings or anxiety
Difficulty conceiving
Other (please explain)
Have you been told you have insulin resistance or prediabetes?
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Yes
No
Not Sure
What are your primary goals right now? (Example: fat loss, hormone balance, fertility, confidence, energy)
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If weight loss is a goal, how much weight are you hoping to lose?
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Are you currently trying to conceive or planning to in the future?
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Yes, actively trying
Yes, in the future
No
Not sure
Why is achieving these goals important to you right now?
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If nothing changes over the next year, how would that make you feel?
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How would you describe your current relationship with food?
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Very structured
All-or-nothing
Inconsistent
Stressful
Neutral
What approaches have you tried in the past? (Select all that apply)
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Calorie tracking
Low carb / keto
Intermittent fasting
Meal plans
Weight loss medications
Working with a coach
None
What worked temporarily? What didn’t work long-term?
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Do you feel confident eating carbohydrates?
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Yes
Somewhat
No
Do you often experience cravings, energy crashes, or overeating episodes?
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Yes
Sometimes
Rarely
What does movement currently look like for you? (Select all that apply)
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Walking
Strength training
Group fitness
Cardio-heavy workouts
Inconsistent
None right now
How many days per week are you realistically able to move your body?
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Do you have any injuries, limitations, or medical considerations we should know about?
*
What do you feel has held you back from long-term success in the past?
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When life gets busy or stressful, what usually happens with your health habits?
On a scale of 1–10, how ready are you to commit to a structured, long-term approach?(1=not ready) (10=committed)
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This program is a 12-month commitment designed for sustainable results. Does that feel aligned with what you’re looking for?
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Yes
I have questions
No
What kind of support do you feel you need most?
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Nutrition guidance
Accountability
Hormone education
Structure
All of the above
Do you believe your health is worth investing in?
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Yes
I want to, but I have concerns
Are you financially prepared to invest in a high-touch, year-long coaching program if it’s the right fit?
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Yes
Possibly, with options
No
Is there anything that would prevent you from moving forward if accepted?
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I understand this application is not a guarantee of acceptance and is used to ensure alignment.
Yes
I am ready to take the next step toward improving my metabolism, hormone health, and long-term well-being.
Yes
Submit Application
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