Full Name
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Email Address
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Phone
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Address
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City, State, Zip
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Do you have significant fatigue, lethargy, or sluggishness?
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Do you have a history of Low Thyroid in your family?
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Are you often colder than others around you?
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Have you ever been diagnosed with an auto-immune disease?
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Do you suffer from skin problems such as acne, eczema or dry skin?
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Do you have difficulty with excess weight?
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Do you have difficulty losing weight?
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Do you have brittle, dry hair?
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Do you get red faced when exercising and have difficulty perspiring?
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Do you suffer from depression or moodiness for no apparent reason?
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