Name *

First Name

Last Name

Phone *

Country

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Please check all statements that apply. *

Sometimes...

I crave or consume sweets, salty or junk food

I experience irritability, nervousness, or low spirits

I experience poor concentration or memory

I have a stressful or sedentary lifestyle

I experience belching, gas or discomfort after meals

I have fewer than two bowel movements a day

My sleep is restless or I lack sleep

I lack energy or have chronic fatigue

I have thinning hair or balding

I have hot flashes, sweats and irregular body temperature

I have prostate and/or impotence issues

I have difficulty breathing

I have a chronic cough

I experience unexplained chronic issues (arthritis, headaches, skin)

My joints feel sore, achy, or stiff

I frequently use antibiotics

I have skin sensitivity or am prone to breakouts like acne, eczema, or psoriasis