First Name
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Last Name
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Email
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Phone
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Gender:
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Male
Female
Non-binary
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For men, do you have a history or suspected LowT?
*
Yes
No
I am a woman
For women, do you have an apple shape?
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Yes
No
I am a man
Do you have any issues with swelling or water retention (feet face, fingers?)
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Yes
No
Do you feel very stressed often?
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Yes
No
Do you have anxiety?
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Yes
No
Do you have depression?
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Yes
No
Do you frequently feel like you skip a BM or that the BM doesn’t quite feel complete?
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Yes
No
Do you burp?
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Yes
No
Do you feel symptoms of acid reflux?
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Yes
No
Do you take less than 5k steps/day?
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Yes
No
Are your breaths generally shallow?
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Yes
No
Have you every had a blood clot?
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Yes
No
Do you hate the taste of water?
*
Yes
No
Does water make you bloat?
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Yes
No
