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Are you over 21 years of age?
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Yes
No
What is your Height (cm)?
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What is your weight (kg)?
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Are you pregnant, trying, or breast feeding?
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Yes
No
Are you a smoker?
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Yes
No
Do You Have A Current Medical Conditions?
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Yes
No
Do you have High Blood Pressure?
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Yes
No
Do you have diabetes?
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Yes
No
Do you have a heart condition?
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Yes
No
Do you have cancer?
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Yes
No
Are you currently on medication?
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Yes
No
Do you have any previous medical conditions?
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Yes
No
Do you have a family history of significant medical conditions?
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Yes
No
Do you have shortness of breath or wheezing?
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Yes
No
Do you have difficulty swallowing?
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Yes
No
Do you have chest pain?
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Yes
No
Do you cough?
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Yes
No
Are you coughing with mucus or blood?
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Yes
No
Do you feel pain when breathing?
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Yes
No
Do you have heart palpitations?
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Yes
No
Do you have childhood asthma?
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Yes
No
Do you suffer from frequent headaches?
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Yes
No
Do you suffer from neck stiffness?
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Yes
No
Do you have issues with vision?
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Yes
No
Do you have sensitivity to light or noises?
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Yes
Yes
Do you have Sudden Weakness or Numbness?
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Yes
No
Do you have trouble with coordination?
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Yes
No
Fits?
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Yes
No
Have a fainting issue?
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Yes
No
Do you feel confusion or disorientation?
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Yes
No
Do you have nausea?
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Yes
No
Are you suffering from heartburn?
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Yes
No
Are you vomiting or facing reflux?
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Yes
No
Do you have diarrhea?
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Yes
No
Do you have constipation?
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Yes
No
Are you feeling yourself that you’re having an unexpected weight loss?
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Yes
No
Are you suffering from abdominal pain?
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Yes
No
Do you have urinary or bladder pain?
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Yes
No
Do you have frequent urination?
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Yes
Yes
Any of the following such as loin pain, incontinence, impotence, testicular lumps or pains, penile discharge or lesions?
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Yes
No
Do you have joint pain or stiffness?
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Yes
No
Do you have deformity?
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Yes
No
Do you have swelling?
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Yes
No
Do you have sciatica?
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Yes
No
Do you have poor sleep at night?
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Yes
No
Are you an early morning wake up person?
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Yes
No
Do you have panic attacks?
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Yes
No
Do you have eating disorders?
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Yes
No
Do you have postnatal depression? (P.N.D)
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Yes
No
If a doctor has told you before that you have a special kind of sickness in your mind or feelings, can you tell us what it is?
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On a regular day, how stressed do you feel?
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On a regular day, how stressed do you feel?
High
Medium
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If you intend to order IGF then you need to do a blood test first and send the results before you can order it. Kindly submit the blood test results:
*
If you intend to order IGF then you need to do a blood test first and send the results before you can order it. Kindly submit the blood test results:
Submit proof of age such as upload drivers license, please.
*
Submit proof of age such as upload drivers license, please.
Have you ever used or ordered Via Co Lab’s any medicine therapy Online before?
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Have you ever used or ordered Via Co Lab’s any medicine therapy Online before?
Yes
No
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Was the service professional?
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Was the service professional?
Yes
No
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Did you have an opportunity to speak with a pharmacist or doctor?
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Did you have an opportunity to speak with a pharmacist or doctor?
Yes
No
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Have you experienced any side effects?
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Have you experienced any side effects?
Yes
No
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Have you seen positive results?
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Have you seen positive results?
Yes
No
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Has your overall health improved as a result?
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Has your overall health improved as a result?
Yes
No
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Did the benefits of the Peptides Online outweigh the expenses involved?
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Did the benefits of the Peptides Online outweigh the expenses involved?
Yes
No
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Would you recommend Via Co Labs to friends or family?
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Would you recommend Via Co Labs to friends or family?
Yes
No
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How did you hear about us?
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Search Engine
Social Media
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Expo
Friend or Family
Blog
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First Name
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Last Name
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Date of birth
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Phone
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Address
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Email
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