Do you suffer from skin irritation and dryness?
Never
1-2 times per month
Weekly
Daily
Do you experience dry eyes?
Never
1-2 times per month
Weekly
Daily
Do you suffer from low mood or depression?
Never
1-2 times per month
Weekly
Daily
Do you experience joint pain and stiffness?
Never
1-2 times per month
Weekly
Daily
Do you suffer from thinning or loss of hair?
Yes
No
Do you experience poor concentration?
Never
1-2 times per month
Weekly
Dailiy
Do you suffer from declined cognitive function?
Yes
No
Do you experience excessive ear wax?
Never
1-2 times per month
Weekly
Daily
Do you suffer from allergies?
Yes
No
Do you experience trouble sleeping?
Never
1-2 times per month
Weekly
Daily
Do you suffer from a difficult menstrual cycle?
Yes
No
N/A
First Name
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Email
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