Body Balance Movement Request for Information

1
Please share the best email address where we can send information.* This field is required.
example@example.com
2
What is your name?
First Name
Last Name
3
What is the best phone number to contact you at if needed?* This field is required.
4
Where are you located so we can send you the correct pricing in your currency?* This field is required.
5
Let's build your free plan:* This field is required.
6
Which best describes you?* This field is required.
New to health and fitness (have not had professional help before, or just tried things on my own, or have never tried anything)
My body is stuck (I'm doing everything I can think of with food and exercise but my weight and body are not budging)
I'm a pro, but want to get faster results (I know exactly how to help my body and am getting results already, I now want to balance my hormones and get faster results)
I only want to balance hormones (I am not looking for weight loss, but I have hormones I'd like to get into balance and feel better)
Other
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Please check off which of these sound like you, your supplement package will be selected according to your needs. (Select all the apply.)* This field is required.
Hormone Balancing (I want to manage my hormonal symptoms and I want my weightloss to speed up)
Visceral Fat Burning (I want to shrink my waist and belly and get rid of the stubborn fat sitting behind my abdomen and surrounding my organs)
Control cravings and overeating (I want to feel full and satisfied when I eat, and not crave foods unnecessarily)
Gut Health Improvement (I have taken medications, antibiotics, painkillers at some point in my life, and can feel something is not right with my gut. I am either constipated or have loose stools, or feel bloated. I want a healthy release).
Other
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What are you looking for? (Select all that apply.)* This field is required.
Need support with my weight management goals
Improve health
Balance hormones
Build muscle
Healthier lifestyle
Want more energy
Want to sleep better at night
Want to look and feel more lean and fit
Want to cleanup my gut
Health concerns (please specify below if you can)
Other
9
Do you have any of these conditions (Select all that apply.)?* This field is required.
Perimenopause
Menopause
PMOS/PCOS
Type I Diabetes
Type II Diabetes
Pre-diabetic
Leaky Gut
High Blood Pressure
Hyperthyroidism
Hypothyroidism
Insulin Resistance
Iron Deficiency/Anemia
None
Other
10
Here are some hormonal imbalance symptoms, which of these apply to you currently? (Select all that apply).* This field is required.
Headaches
Mood swings
Digestion/Gut/Bloating issues
Low libido
Weight gain
Trouble losing weight
Night sweats
Food cravings
Feeling sad/off/depressed
Inflammation
Hot flashes
Hair thinning/falling
Acne/Skin issues
Joint pain
Poor sleep quality
Brain Fog/Lack of focus
Fatigue/tiredness
Fertility issues
Excessive sweating
Skin tags or pigmentation on neck/underarms
Swelling on face/hands/feet
Other
11
Which other programs or routines have you tried in the past to try to get healthier?* This field is required.
Keto Diet
Soup Diet/Juicing/Limited calories
Dr. Bernstein
Dr. Poon's
Weight Watchers
Gym/Exercise
Personal Trainer/Group Classes
Just trying to eat clean on my own
Just trying workouts on my own
I have never tried anything before
Other
12
What would you ideally like to see happen? (Check all that apply)* This field is required.
Lose weight on the scale
Lose inches around the body so clothes fit better
Maintain my current weight and size, but get my body stronger/healthier
Gain weight/inches to be at a healthy size/weight
Balance hormones
Get rid of unpleasant hormonal symptoms
Other
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How actively do you currently exercise?* This field is required.
None
1 to 2 days a week
3 to 4 days a week
5 to 7 days a week
14
Do you currently take any nutritional products to help support your system and health? For example, like protein, fibre, collagen support, digestion support, vitamins etc* This field is required.
No
Other
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Are there any health issues or concerns in particular that you would like to share with us? If you have a diagnosis, or taking medication, it is important that you share this information so that we can respond accordingly.* This field is required.
16
What are some of the obstacles in your daily life right now that currently prevent you from being your ideal healthy self?* This field is required.
No obstacles, I am ready to begin.
Lack of self control
Limited time to cook healthy meals
Too socially active
Sweet tooth
Shift work or difficult schedule
Do not stay committed to anything for long
I only enjoy delicious flavorful food
Other
17
If I could show you how to achieve your goals without giving up delicious food and still feeling fulfilled each day, would you be ready to begin?* This field is required.
Yes! This is what I have been looking for!
I am not sure, I would need more information first about the program and how it works.
18
Where did you come across Body Balance Movement?* This field is required.
Instagram
Facebook
On a Website
Google
Personally Sent Link
Other
19
When is a good time to get in touch with you? (check all that apply)* This field is required.
Morning (9am to 11:30am)
Afternoon (12pm to 4:30pm)
Evening (5pm to 8:30pm)
Late Night (9pm to 11:30pm)
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Is there anything else you would like to share with us?* This field is required.
21
So that you are not kept waiting, our system will automatically send you information with pricing details for USA and Canada.
If you have indicated you are in another country, please give us up to 48 hours to get back to you.
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