Ready to Take Control of Your

HORMONE HEALTH?

Please answer the below questions to help evaluate your eligibility for this program.

"*" indicates required fields

Please select your age range.*

18-24

25-39

40-59

60+

Do you experience low mood or mood swings?*

Never

Sometimes

Frequently

Always

How often do you feel stressed or anxious?*

Never

Sometimes

Frequently

Always

Have you experienced weight gain in the last 6-12 months?*

No

Mild

Moderate

Severe

Do you have joint discomfort or aches?*

No

Mild

Moderate

Severe

How would you rate your energy level?*

(5 is high energy, 1 is low energy)

5

4

3

2

1

How would you rate your sleep quality?*

(5 is excellent, 1 is poor)

5

4

3

2

1

How would you rate your mental clarity and focus?*

(5 is high, 1 is low)

5

4

3

2

1

How would you rate your libido/sex drive?*

(5 is high, 1 is low)

5

4

3

2

1

Consent

Yes, I'd like to receive updates and information from Biote.

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Consent Hidden

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First Name

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Last Name

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Email

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Phone

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Zip

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Entry ID

Comments

This field is for validation purposes and should be left unchanged.