Optimal Wellness Survey - Cobb Wellness and Aesthetics

Name: *

Wnat is your date of birth? Month-Day-Year

Email *

What is your gender?

Phone

What would you like to improve?

Are you taking hormone replacement (sex hormones and/or thyroid hormone replacement?

If yes, what are you taking?

If yes, do you feel good with what you are taking?

What medications are you taking?

What supplements are you taking?

If no, are you interested in starting a hormone program?

Do you have any medical condition or concerns what we should know about?

Do you have any gut issues like irritable bowel or Crohn's disease?

Have you ever been diagnosed with cancer?

If yes, what kind of cancer and what was your trearment?

Do you suffer from anxiety or depession?

If so, are you on a treatment plan?

How often do you consume alcohol?

What is your relationship to exercise and physical activity?

How often do you exercise in a week?

What type of exercise do you do?

If so, how much are you looking to lose?

Do you wake up feeling rested and restored?

Do you feel stressed?

What kind of stresses are you dealing with?

Do you have an injury or aches in your joints?

Is it easy for you to recover from a workout?

If not, how long does it take you to recover?

Do you have any gut issues like Crohn's or Colitis or suffer from bloating?

Do you suffer from brain fog?

Do you confirm that you have answered all questions truthfully? *