What's your name?
Let's get to know each other before we
dive into the quiz.
Full Name
Phone Number
*
Email
*
Do you have chronic digestive problems, such as bloating, diarrhea, ulcers, reflux, or indigestion?
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Yes
No
Are you constantly tired and lethargic?
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Often
Seldom
Do you crave carbohydrates, such as rice, bread, and sugary sweets?
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Yes
No
Do you experience symptoms of hypoglycemia, such as shakiness, irritability, or dizziness?
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Yes
No
Have you experienced extreme stress, anxiety or depression in the last 5-8 years?
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Often
Seldom
Do you drink coffee regularly?
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Yes
No
Do you overwork or overexercise?
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Yes
No