Full Name
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Phone
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Email Address
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Address
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City, State, Zip
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Do you suffer from Diabetes, Atherosclerosis, or Heart Disease?
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Do you have an autoimmune disorder?
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Do you suffer from Irritable Bowel Syndrome?
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Do you suffer from arthritis or other joint problems?
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Are you overweight by more than 30 pounds?
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Do you consume more than 2 alcoholic beverages per day?
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Do you exercise LESS than 30 minutes, three times per week?
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Do you suffer from seasonal allergies or food allergies?
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Do you have an excess amount of stress in your life?
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Do you consume a diet that is high in refined carbohydrates?
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