Bosom Naturale

Self-assessment questionnaire

Your answers to the following questions are solely for the purpose of determining whether Bosom Naturale, the all-natural breast enhancement supplement, will help you achieve the look you want. This does not guarantee individual outcomes since each woman responds differently to Bosom Naturale’s formulation. Further, this is in no way an attempt to diagnose medical conditions.

All answers are confidential. Never provide your name in this section, even if requested.

1. How old are you?
Under 18 18 - 24 25 - 30 31 - 35 36 - 49 50 +

2. How many children do you have?
None One Two Three +

3. How long since the birth of your last child?
N/A Less than six months Between six months and one year Greater than one year

4. Did you nurse your children?
N/A Yes No

5. Are you now being treated, or have you ever been treated, for any of the following?
(Check all that apply)
Growth problems
Immune system disorders
Cancer
Hormonal/endocrine disorders
Diabetes
None of the above

6. If so, are you currently under a doctor’s care and taking medications?
N/A Yes No

7. Do you have, or have you ever had, a problem with obesity?
Yes No

8. Are you currently on a diet program?
Yes No

9. If you answered yes to Q8, does your diet include any prescribed medications?
N/A Yes No

10. Are you now taking supplemental estrogen?
Yes No

11. Do you smoke?
Yes No

12. What are your goals for breast enhancement?
Overall firmness, fullness 1 - 2 cup sizes 3 or more cup sizes

13. Is modest or small breast size a family trait?
Yes No

14. Have you tried other breast-enhancing supplements?
Yes No

15. If answer to above question is yes, please check which brands:
Bloussant Cleavage Femenique Other None

16. Have you ever had surgical breast implants?
Yes No

17. If answer to Q16 is yes, do you still have the implants?
N/A Yes No

18. If answer to Q17 is yes, what are your goals for Bosom Naturale?
(Check all that apply)
N/A
To mask presence of implant
Provide fullness
Reduce ridging affect
Increase size

19. Do you exercise regularly?
Yes No

20. Does your exercise routine include weight training?
Yes No

21. If you drink coffee or other caffeinated drinks, how many cups per day?
Don't drink caffeinated drinks 1 -3 cups 4 - 6 cups 7 +

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*These statements have not been evaluated by the food and drug administration. The products mentioned are not intended to diagnose, treat, cure or prevent any disease. Always see your licensed health care professional for proper diagnosis and treatment.