Health & Wellness QuestionnaireComplete this form to take the first step toward optimizing your health. PERSONAL INFORMATION Name * First Name Last Name Date of birth * MM DD YYYY Email * Phone * Country (###) ### #### Preferred contact method * Text Phone call Email Gender * Male Female Shipping address * Address 1 Address 2 City State/Province Zip/Postal Code Country Occupation HEALTH GOALS What are your primary health goals? Select all that apply Weight loss Muscle gain Hormone optimization Increased energy & vitality Improved sleep & recovery Sexual health & libido Mental health & stress management Hair loss prevention & regrowth Anti-aging & longevity Other HEALTH CONCERNS Do you have any current health concerns? Select all that apply Low energy or fatigue Poor sleep or insomnia Low libido or sexual dysfunction Weight loss resistance Unexplained weight gain Hormonal imbalance (PMS, Menopause, PCOS, etc.) Digestive issues (Bloating, Acid reflux, IBS, etc.) High stress or anxiety Hair thinning or hair loss Other ADDITIONAL INFORMATION How soon are you looking to get started? Immediately Within the next 30 days Just researching How did you hear about us? Select all that apply Instagram Facebook Google YouTube Referral Other Comments Tell us anything specific about your health journey. MEDICAL DISCLAIMERS & CONSENT BioGen medical disclaimer * By checking this box, I acknowledge I have read and agree to the Telehealth Informed Consent, Terms and Conditions, Medical Group’s Notice of Privacy, BioGen Privacy Policy, and Consumer Health Data Privacy Policy. Consent for communications * I agree to receive text messages and emails from BioGen Restoration regarding my account, services, and promotions. Message and data rates may apply. Message frequency varies. Thank you! A team member will reach out to discuss your next steps.