1

Are you male or female?

Male

Female

How much weight would you need to lose to achieve your ideal weight?

Less than 15 pounds

More than 15 pounds

Have you experienced any of the following genitourinary symptoms?

Select all that apply.

Vaginal Atrophy

Vaginal Dryness

Painful Intercourse

Urinary Incontinence

Frequent Urination

None

Have you struggled with any of the following gastrointestinal symptoms:

Select all that apply.

Bloating

Gas

Constipation

Diarrhea / Loose Stools

Abdominal Discomfort with Meals

None

Do you believe your chronological age (the number on your driver's license) matches your biological age (how you look/feel)?

Yes, I look/feel my age

No, I look/feel older than my age

How many vitamins or supplements do you take on a daily basis?

None

1-4

5+

Have you ever tried to “reset” your body’s overall health through a gut or liver detox program?

Yes

No

First Name*

Last Name*

Phone*

Email