What is your gender? *

Male

Female

How old are you? *

Under 40

40-50

50-60

60 or Above

I would describe my weight as: *

Underweight

Average

Slightly Overweight

Moderately Overweight

More than 75 lbs Over weight

My energy level is: *

High

Average

Occasionally tired for no obvious reason

Frequently Tired

Feeling continuously exhausted

I tend to feel: *

Positive and optimistic

Occasionally frustrated

Often tense and frustratedaverage

Depressed

I exercise: *

Everyday

Often

Occasionally

Rarely

Never

I would describe my sleep patterns as: *

I sleep all night and feel rested in the morning

I sleep without interruption but wake up tired

I have trouble sleeping

I rarely sleep well

I experience muscle and/or joint aches:

Very rarely

From time to time

Relatively frequently

Persistently

First Name *

Last Name *

Phone *

Email *

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