My name is...

I am ...

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I'm between the ages of...

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I'm allergic to...

• Dairy

• Fish

• Milk

• Nuts

• Sesamin

• Shellfish

• Soybeans

• Tree nuts(almond, wlnut etc)

• Wheat

My diet is mainly...

Right now, I'm taking these supplements...

I'm currently on medication for...

I have the following medical conditions...

I often have trouble falling asleep

• True

• False

I often wake up from sleep still getting tired

• True

• False

I often feel stressed...

• True

• False

I have a family history of cardiovascular conditions

• True

• False

I have a family history of cognitive conditions

• True

• False

I occasionally face digestive concerns

• True

• False

I sometimes experience joint pain

• True

• False

I have been experiencing this joint pain for a while

• True

• False

I experience joint pain while exercising for which I often take pain killers

• True

• False

I enjoy exercising & need more energy for it

• True

• False

My blood cholestrol is usually high

• True

• False