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 get a cold or the flu more than once per year?
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Do you suffer from infections of the nose, sinuses, ears, or throat often?
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Are you frequently tired or fatigued?
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If you do get sick, is your body able to overcome the illness without help?
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Do you suffer from an autoimmune condition?
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Are you or have you been exposed to a high level of environmental toxins?
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Do you suffer from an immune-suppressant disorder?
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Do you suffer from allergies?
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Do you suffer from a high level of stress?
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Do you take a multi-vitamin/mineral supplement daily?
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