CONSULTATION
Are you?
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Male
Female
What's your age group?
25 - 35
36 - 45
46 - 55
56 - 65
65 and older
Tell us about your lifestyle (so we can tailor the style to fit your daily life)?
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Workout
Sweat alot
Office work
Minimum Sweating
Other
What's your biggest problem and pain?
Are you currently taking medication to assist with your pain management?
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Yes
No
If you could wave a magic wand to solve your pain, how would you do it?
If you could solve your pain naturally, would you do it?
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Yes
No
Do you have a hard time getting to sleep?
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Yes
No
Do you sleep through the night?
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Yes
No
Do you suffer from brain fog?
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Yes
No
Would you like to increase your mental clarity naturally?
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Yes
No
Would you like to start your day loosing stubborn unwanted pounds naturally??
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Yes
No
First Name
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Last Name
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E-mail Address
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Mobile Number
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-
Area Code
Phone Number
Date you want consultation
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Month
-
Day
Year
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