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
www.urnotalone.com
www.tglife.com
Google
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? Male Female

How old are you?

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
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 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 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 occasional pimples or acne.
I get severe pimples or acne.

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 FSI)
NO YES