Name* First Last Email* Phone*Location* Age Rate yourself on how you feel based on 100% being the highestEnergy Level Memory Libido & Desire Skin Quality Recovery Time Drive Motivation Sleep Quality Muscle Tone Concentration Symptoms – Please check all that applySymptoms Arthritis / Stiffness Anxiety Bladder Symptoms Blood Pressure Low Cancer Decreased Libido Diabetes Dizziness Diarrhea Osteoporosis Muscle Weakness Headaches Heart Palpitation Hight Blood Pressure Mood Swings Drowsiness Insomnia / Sleep Disturbances Fatigue Forgetfulness Food Cravings Acne Dry Hair Facial Hair Hair Loss from Scalp Hair Loss - Other Joint or Back Pain Dry Skin Oily Skin Skin Wrinkles Excessive Sweating Depression Irritability Decreased Sense of Sexuality Decreased Sexual Arousability Harder to Reach Climax Erection Problems Heat Intolerance Sensitive to Temperature Swings Temperature Swings Low Temperature Weight Gain Weight Loss When is it the best time to call? Morning Afternoon Evening Any Other Concerns?
