Thank you for taking the time to fill out your personal profile to ensure the best results from your program. Your profile will be entered into our database and will remain confidential. You can also call us toll free at 1-888-961-0800 and interact directly with one of our customer care representatives who would be pleased to take your personal profile over the phone.
Where did you see our advertisement? (check all that apply, choose at least one) Glamour Cosmo Parenting Baby Talk Girl Talk Health Complete Woman US Weekly Woman's Day Woman's Own Bride's Modern Bride Google Facebook I did not see an advertisement Other
First Name Last Name
Address: Apt: Address (Line 2): City / Town: State / Province: Zip / Postal Code: Country:
Daytime Phone: - -
Evening Phone: - -
E-mail Address: What sex are you? Female Male
How old are you?
How many children have you had, if any? - Select One - None 1 2 3 4 5 or More
Do you smoke cigarettes? How many a day? - Select One - I do not smoke cigarettes. Rarely 5 cigarettes or less a day About 1/2 a pack a day About a pack a day More than a pack a day
How often do you eat chocolate? - Select One - Once a Day Five Times a Day Once a Week Never
How many cups of caffeinated beverages do you drink a day? (There is caffeine in coffee, sodas like Coke, Pepsi & Mountain Dew, and many kinds of tea.) - Select One - None 1-2 cups a day 3-4 cups a day 5 cups or more a day
Are you diabetic? (Our product contains some herbs that may normalize blood sugar levels.) NO YES
Are you bipolar or schizophrenic? I have not been diagnosed as bipolar or schizophrenic. I am, but I am not on anti-seizure medication for it. I am, and I am on anti-seizure medication for it
How much do you weigh?
Have you gained or lost 10 or more pounds in the last 6 months? - Select One - My weight has been pretty stable I gained more than 10 lbs I gained more than 20 lbs I lost more than 10 lbs I lost more than 20 lbs
How tall are you? Feet Inches
What is your blood type? - Select One - I am not sure A- A+ B- B+ AB- AB+ O+ O-
Do you engage in any types of regular physical exercise? Choose the activity that you do most often, or that best describes your lifestyle.) - Select One - My lifestyle is really not very active. I try to fit excercise into my life, but its not easy. I go to the gym. I work out at home. I walk a mile or more. I participate in a number of outdoor activities. I have a generally active lifestyle or job. How many days a week do you exercise?
How would you rate your metabolism? (Your metabolism is the ability of your body to process food into energy) LOW MEDIUM HIGH VERY HIGH If you ever wore a different size, please list it here: Number Letter - Select One - A AA B BB C CC D DD E EE F FF (If you were several different sizes, select the one that was most different from your current size.)
What size bra do you wear now? Number Letter - Select One - A AA B BB C CC D DD E EE F FF
What would you attribute your change in bra size to? (check all that apply, choose at least one) I lost weight, and lost breast size I gained weight, and gained breast size My breasts got larger while I was pregnant, or breastfeeding After pregnancy, or breastfeeding, my breasts went back to the size they were before. After pregnancy, or breastfeeding, my breasts got smaller than they were before. I have not seen a change in my bra size.
Please tell us a little about your goals for the program: (check all that apply, choose at least one) I would like to restore, or increase, the firmness of my Breast. I would like to make my breasts rounder and fuller. I would like to give my breasts more of a lift. I would like to increase my breast size slightly, (less than 1 cup size increase.) I would like to increase my size significantly, (1-2 cup sizes.) I would like to increase my size dramatically, (2 cup sizes or more.) I would like to see benefits to my hair, nails, and skin. I would like relief from symptoms of low estrogen. I would like to see an increase to my libido (sexual desire.) I would like to enhance my orgasms.
Please help us in gauging your hormone levels, by answering as accurately as possible: (check all that apply, choose at least one) I have slight, dark, facial hair, on my upper lip, like the kind that some women bleach or wax. I have dark hair on my arms, legs, or body. I occasionally get random hairs on my chin, neck, or breasts. I regularly sleep less than 7 hours a night. I get headaches specifically associated with my period. I get occasional pimples or acne. I get severe pimples or acne. None of the Above Apply
Have you had a hysterectomy? (An operation during which a woman's uterus is removed) NO YES
Do you have both of your ovaries? YES NO, I only have one. NO, they were both removed.
Would you like one of our customer care representatives to call you in the next couple of days? NO YES
Would time of day would be best to call you? Daytime Evening Either One
Which days of the week would be best for us to contact you? (check all that apply, choose at least one) Any Day of the Week Monday Tuesday Wednesday Thursday Friday Saturday Sunday Please Do Not Contact Me By Phone
Would you like one of our customer care representatives to send you additional information in the mail? (The package comes in a plain business envelope with the name Fundamental Science, Inc.) NO YES
