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Book Your Consult!
Home
About Us
How It Works
Success Stories
Other Conditions
Headaches
Digestive Issues
Low Engery
Thyroid Issues
Diabetes Issues
Book Your Consult!
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Step
1
of 7
Do you feel shaky, light headed or irritable if meals are missed?
*
Never
Sometimes
Always
Do you crave sweets during the day or after meals?
*
Never
Sometimes
Always
Do you feel fatigued after meals?
*
Never
Sometimes
Always
Next
Do your hands and feet feel cold?
*
Never
Sometimes
Always
Do you require excessive amounts of sleep in order to function properly?
*
Never
Sometimes
Always
Do you struggle with feeling tired or sluggish?
*
Never
Sometimes
Always
Back
Next
Do you have trouble falling or staying asleep?
*
Never
Sometimes
Always
Do you find yourself craving salt?
*
Never
Sometimes
Always
Are you a slow starter in the morning?
*
Never
Sometimes
Always
Back
Next
Do you have heartburn or use antacids?
*
Never
Sometimes
Always
Do you experience excessive belching, burping or bloating?
*
Never
Sometimes
Always
Do you experience diarrhea and/or constipation?
*
Never
Sometimes
Always
Back
Next
Rate your energy level on a daily basis from 1 - 10
*
1 = little to no energy, 10 = high energy
Have previous weight loss attempts produced sustainable results?
*
Yes
No
What were the results and for how long did they last?
*
How many pounds would you like to use?
*
10 LBS. or Less
20 LBS.
30 LBS.
40 LBS.
50 LBS. or more
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Next
Rate your desire to achieve those results on a scale of 1-10.
*
1 = low desire, 5 = moderate desire, 10 = high desire
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Next
First Name
*
Last Name
*
Email
*
Phone Number
*
Message (Optional)
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