Full Name
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Phone Number
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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 hot flashes?
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Do you suffer from periods of mood swings or depression?
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Have you taken Hormone Replacement Therapy in the last 2 years?
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Do you often awake at night with excessive perspiration?
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Are you excessively nervous or do you suffer from anxiety?
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Do you have 'spells' of weakness, low blood sugar or fatigue?
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Do you suffer from excess stress in you life?
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Do you have any adult onset allergies?
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Do you have cravings for starch or sugar-rich foods?
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Are you over the age of 50?
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