Multi Step Form - AlfaGenix

Step 1 of 19

YOUR FULL NAME*

Please enter your name as it appears on your government-issued document.

Your Gender*

Male

Female

What are Your goals?

What are your goals?*

Increased Libido

Increased Stamina

Hair Growth

Weight Loss

Increased Energy

Better Sleep

Clear Skin

Mental Clarity

How much weight would you like to loose?

How much weight would you like to loose?*

Lose 1-20 lbs

Lose 21-50 lbs

Lose over 50 lbs

Maintain Weight

I haven’t decided yet

Please enter your height and weight

In feet/inches and pounds.

Height (feet)

Please enter a number greater than or equal to 1.

Height (inch)

Please enter a number greater than or equal to 1.

Weight

Please enter a number greater than or equal to 1.

What best describes your Monthly Cycles?

Monthly Cycles*

It’s Regular

I’m on Birth Control

it’s Irregular

Last Period over a year ago

What type of birth control are you on?

What type of birth control are you on?*

Copper IUD

Mirena UID

Pills or Patches

Other

Hormone optimization requires stopping
use of any synthetic birth controls.
Are you ok with that?

Hormone optimization requires stopping use of any synthetic birth controls. Are you ok with that?*

Yes

What symptoms are you experiencing?

What symptoms are you experiencing?*

Hot Flashes

Night Sweat

Brain Fog

Memory Loss

Water Retention

Fatigue

Depression

Low Libido

Vaginal Dryness

Daytime Sleepiness

How severe are these symptoms?

Hot Flashes*

1 Mild	2	3 Moderate	4	5 Severe

What symptoms are you experiencing?

Below are some progesterone-related issues

What symptoms are you experiencing?

Anxiety

Agitation

Water Retention

Tender Breasts

Bloating

Mood Swings

Joint Pain

Insomnia

Depression

Heavy Mensuration

How severe are these symptoms?

Mood Swings*

1 Mild	2	3 Moderate	4	5 Severe

Insomia*

1 Mild	2	3 Moderate	4	5 Severe

What symptoms are you experiencing?

Below are some thyroid-related issues

What symptoms are you experiencing?

Fatigue

weight Gain

Inability to lose weight

Heat Intolerance

Cold Intolerance

Hair Loss

Brittle Nails

Dry Skin

Constipation

Joint Pain

How severe are these symptoms?

Hair Loss*

1 Mild	2	3 Moderate	4	5 Severe

Fatigue*

1 Mild	2	3 Moderate	4	5 Severe

What symptoms are you experiencing?

Below are some testosterones-related issues

What symptoms are you experiencing?

Acne

Only Skin

Excessive Sweating

Abnormal Hair Growth

Hair Loss

Increased Libido

Low Libido

Fatigue

Memory Loss

Wrinkles

Weight Gain

Loss of Muscle Mass

Brain Fog

How severe are these symptoms?

Oily Skin*

1 Mild	2	3 Moderate	4	5 Severe

Wrinkles*

1 Mild	2	3 Moderate	4	5 Severe

Do any of the following conditions apply to you?

Some of the below conditions may disqualify you from Thrivelab.

PCOS

Diabetic or Pre-diabetics

Thyroid Disease

History of cancer

Liver Disease

Pregnant

Unexplained Masses

Tried Hormone Therapy in the past

On Hormone Therapy now

Sugar Cravings

Other symptoms

Do you have any symptoms that weren’t mentioned here?

Please enter your date of birth

This is to ensure you meet the age requirements for our programs.

This is to ensure you meet the age requirements for our programs*

MM slash DD slash YYYY

How can we get in touch?

We’re almost done!

EMAIL ADDRESS*

PHONE NUMBER*

Consent*

I agree to the Terns and Conditions and Privacy Policy*

Your Results!

Hi Sdadas, After analyzing your self-assessment responses, it appears your Testosterone imbalance and Progesterone imbalance and Testosterone Imbalance levels are high. Take a look at our Probability of Imbalance scale to better understand your hormone balance mix.

Estrogen Imbalance 20%

Thyroid Imbalance 36%

Testosterone Imbalance 30%

Progesterone Imbalance 40%