Personalized Foundation Game Plan: Intake Form

Section 1: The Basics

Full Name *

Email *

Instagram or FB Handle (So I can send your plan directly!)

Country of Residence (This helps me tailor your product recommendations and shipping options!) *

Current Hormonal Stage:

Perimenopause

Menopause

Post-Menopause

I have no idea, help!

Section 2: The "Messengers" (Symptoms)

What are your Top 3 frustrations right now? (Check all that apply) *

• Hair thinning/shedding

• Stubborn midlife belly fat

• Brain fog / Lack of focus

• Zero energy / 3 PM crashes

• Sleep disruptions / Night sweats

• Systemic bloating / Inflammation

On a scale of 1-10, how much is this affecting your daily confidence?

Section 3: The "Terrain" (Current Routine)

Are you currently on BHRT or any hormone medications? (e.g., Estrogen, Testosterone, Progesterone, Thyroid meds) Please list ALL or write NONE if not applicable *

Are you using any GLP-1 support? (e.g., Ozempic, Wegovy, Mounjaro) List which one or NONE or Used to Be

What supplements are you currently taking daily? (List everything—let's see where we can simplify and save you money!)

Do you have any known allergies or dietary restrictions? (e.g., Gluten-free, Dairy-free, Vegan)

Section 4: The Goal

If we could fix ONE thing in the next 90 days, what would it be?

Are you ready to commit to a simple, 3-step daily foundation to see these results? *

Yes!

I have questions first

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🌿 Personalized Foundation Game Plan: Intake Form