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 feelings of fullness after meals?
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Do you have frequent heartburn?
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Have you been diagnosed with acid reflux?
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Do you regularly take antacids - either prescriptions or over the counter?
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Do you often have a sour stomach?
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Do you suffer from upper intestinal gas?
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Do you suffer from constipation and/or diarrhea?
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Are there foods that you just can't eat anymore due to digestive problems?
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Do you suffer from lower intestinal gas?
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Are your digestive disturbances worse in the evening?
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