Part 1:

Please List 3 major health concerns in your order of importance:

1:
2:
3:

Part 2:

Please check the appropriate box on all questions below.

Colon Health

Diarrhea:
NeverSometimesAlways

Digestive Function

Excess belching, bloating or burping:
NeverSometimesAlways

Blood Sugar

Crave sweets during the day:
NeverSometimesAlways

Adrenal Function

Difficulty falling or staying asleep:
NeverSometimesAlways

Gallbladder Function

Have you had your gallbladder removed:
NeverSometimesAlways

Hormone Regulation

Hot flashes:
NeverSometimesAlways

Part 3:

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Additional Info

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