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What is your height?
What is your Weight?
How hard it is for you to lose weight? (1 is very hard, 5 is very easy) 12345
Have you had any bariatric procedures/surgeries in the past? 12345
If yes, please, tell us which surgery/procedure you had in the past.
Have you ever experienced any of these symptoms, fatigue, brain fog, blood sugar crashes and/or join pain? (1 is often and 5 is never ) 12345
How is your sleep? (1 is very bad and 5 is excellent) 12345
How is your exercise routine? (1 is very bad and 5 is excellent) 12345
How is your emotional health? (1 is very bad and 5 is excellent) 12345
How is your stress level? (1 is very high and 5 is very low) 12345
How is your eating habits? (1 is very bad and 5 is excellent) 12345
Please, provide your contact information below.
