First Name *

Last Name *

Email *

Phone *

Do you have more fat around your belly than you'd like? *

Yes

No

Do you have high blood pressure? *

Yes

No

Do you have a family history of heart disease? *

Yes

No

Do you have high levels of blood triglycerides? *

Yes

No

Do you retain water easily? *

Yes

No

Do you have patches of darker-colored skin or little bumps of skin ("skin tags") at your neck, armpits, or other areas? *

Yes

No

Do you have a family member with insulin resistance or Type 2 diabetes? *

Yes

No

Do you have polycystic ovarian syndrome (PCOS; for women) or erectile dysfunction (for men)? *

Yes

No

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