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By taking this survey, you are assisting us in restoring your hormones to their youthful levels.

* Don't spend too long on any one question.
* Your first reaction is typically the most accurate.
* There are no right or wrong answers.
* Answer all questions.
* Do not leave any questions blank!

*Name:

*Email:

*Gender:

Male

Female

*Age:

Do You Have One or More Symptoms of Hormonal Deficiency?

Please read the survey questions below and check the symptoms you have now, or have had in the past.

Decreased Strength

Abdominal Fat

Decreased Libido (sex drive)

Poor Sleep Quality

Joint Stiffness

Hot Flashes

Fibromyalgia

High Cholesterol

Decreased Energy & Stamina

Decreased Mental Sharpness

Thinning Hair

Depression

Prostate Problems (men)

Polycystic Ovary Syndrome (PCOS - women)

Difficult Periods (women)

Fibrocystic Breasts (women)

Hysterectomy (women)

*Please state your health objectives.

Other symptoms you may have.

Any other Health Factors?

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