Full Name
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Email
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Tell me briefly, what are your main health concerns?
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How long have you been experiencing this?
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Are you willing to make dietary and lifestyle changes in order to improve your condition?
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On a scale of 1-10 (with 10 being the most), how motivated are you to get your condition under control?
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10
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What is the best time of day for us to contact you by phone?
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