What's your gender?
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Female
Male
Please tell us how old you are. Many diseases only affect certain age groups. Knowing your age properly allows us to provide a more accurate assessment.
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18-25 years old
26-35 years old
36-45 years old
46-55 years old
56-65 years old
66+ years old
Have you had any of the following symptoms?
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Decrease in muscle mass, with an increase in body fat
Suffer from erectile dysfunction
Started having troubles concentrating and/or lack of feeling sharp
Unexplained depression and decreased sense of wellbeing
Prefer not to say
None
Have you had any of the following symptoms?
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Constantly tired or fatigued
Quick weight gain or loss
Acne
Increased growth of dark facial and/or body hair
Mood swings
Thinning hair or fine, brittle hair
Dry skin
Puffy face
Increased or decreased heart rate
Vaginal dryness (women only)
Heavy menstrual periods (women only)
Hot flashes, night sweats (women only)
Loss of muscle mass
Decrease in sex drive
Prefer not to say
None
Have you had any of the following symptoms?
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Feelings of hopelessness
Feelings of overwhelm
Past events still trigger pain, resentment or anger
Constant worries about the future, ruminating
Nervousness, anxiety, or irritability
Depression
Racing heart and mind
Memory lapses or trouble concentrating
Prefer not to say
None
Have you had any of the following symptoms?
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Frequently upset stomach
Bloating (especially within 1 hour of eating)
Belching or gassiness (especially within 1 hour of eating)
Constipation/infrequent bowel movements
Diarrhea
Heartburn/indigestion
Sense of excess fullness after meals
Bad breath
Discomfort, pain or cramps in your abdominal area
Undigested food in stool
Prefer not to say
None
Were you told your TSH and T4 levels were checked and that these levels are in the normal range?
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Yes
No
Not Sure
Have you had TSH, Total T4, Total T3, Free T4, Free T3, Reverse T3 and antibodies against your thyroid checked on your labs?
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Yes
No
Not Sure
Have you had your CRP or homocysteine checked on labs? (inflammation markers)?
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Yes
No
Not Sure
Have you had your Fasting Insulin checked on labs? *
Yes
No
Not Sure
Do you suffer from diabetes, eczema, psoriasis, lupus, MS, RA, Hashimoto’s, Crohn’s, Celiac’s, gluten-sensitivity or any other autoimmune condition?
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Yes
No
Not sure
Have you been diagnosed with endometriosis, fibroids, PCOS, or PMDD?
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Yes
No
Has your fertility been evaluated by a medical provider?
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Yes
No
Not sure
Have you been diagnosed with unexplained infertility?
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Yes
No
Not sure
How often do you feel stressed?
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Never
Rarely
Pretty Often
Almost Always
How would you define your sleep quality?
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I sleep fine and wake up well rested
I have trouble falling asleep
I wake up a lot during the night, toss & turn
I wake up tired
I have been told I snore
I cannot sleep through the night
I need caffeine in the morning to get me going
I am sleepy throughout the day
I find myself dozing off during the day
Would you say you struggle with any of the following?
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Excessive drinking
Smoking
Drinking too much coffee
Nail biting
Too sedentary, not enough exercise
Over-exercising to manage your stress
Stress eating
Delaying or skipping meals
Consuming food 2 hours before bedtime
Eating too many sweets
Eating too much fast/fried foods
High LDL cholesterol
High blood pressure
Prediabetes/diabetes
Overweight/obese
None of the above
Everyone's unique, so we believe everyone deserves a unique answer. What’s the best time to discuss the implications of your assessment?
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Mornings
Afternoons
Evenings
How motivated are you to work on yourself to feel better?
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I am VERY MOTIVATED to do some work on myself.
I am INTERESTED IN STARTING some changes.
I am UNSURE how much energy I can dedicate to working on myself.
I am NOT READY to participate in changing my routine
Thank you for answering the questions. Get your assessment!
First Name
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Last Name
*
Email
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Cell Phone Number
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I Live In Michigan
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Yes
No
How Did You Find Us
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Referral
Facebook
Instagram
Online Search
Website
Awakening Magazine
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