Health Questionnaire

In our effort to help you maximize the effects of our products, you are kindly requested to fill in the following brief health questionnaire. As soon as we receive it, we will evaluate your answers and provide you with personal instructions for the daily intake of our products (product type - dosage – frequency of use). We assure you that all your answers will be treated with complete confidentiality.

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* 1. Have you tried our products before?

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* 2. How did you fist hear about us?

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* 3. What is your email address?

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* 4. What is your first name?

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* 5. What is your last name?

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* 6. What is your age?

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* 7. What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”.

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* 8. What is your current weight in pounds?

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* 9. Do you suffer from any health problems? If yes, please mention them briefly.

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* 10. Are you receiving any medical treatment for your health problems? If yes please mention type of medication and time of daily intake.

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* 11. Are you under medical treatment for the regulation of your thyroid's gland? If yes, please give details of diagnosis and medication.

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* 12. Are you interested in losing weight? If yes please state how many kilos you wish to lose.

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* 13. Are you interested in gaining weight? If yes please state how many kilos you wish to gain.

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* 14. Which of the following best describes your lifestyle?

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* 15. If you answered vigorously or extremely active, please give us an estimation of how many hours you exercise per day:

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* 16. Do you suffer from Irritable Bowel Syndrome (IBS)? If yes please select one of the following:

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* 17. Do you suffer from any hormonal disorders?

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* 18. Is your menstruation cycle stable (women only)?

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* 19. Are you iron levels within normal range?

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* 20. Do you suffer from hair-loss (women only)?

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* 21. Do your fingernails break easily?

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