First Name
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Last Name
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Gendar
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Gendar
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Are you 18 years of age or older?
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Age
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Is your state Florida, USA?
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How would you describe your current energy levels?
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Do you experience frequent fatigue or brain fog?
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How many hours of sleep do you get on average per night?
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Do you currently take any supplements?
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What are your top wellness goals?
Motion sickness
Traveler’s diarrhea
Altitude sickness
Sun sensitivity or heat intolerance
Cold sensitivity
Anxiety when traveling
Recurrent infections (UTI, yeast, sinus, etc.)
Have you had lab work done in the past 12 months?
Yes
No
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Do you have any of the following conditions?
Motion sickness prevention
Altitude sickness support
Digestive support
Women’s health meds
Men’s health meds
Emergency antibiotics
Jet lag/sleep aid
Do you regularly exercise?
Tablets/capsules
Nasal sprays
Topical/creams
Injections
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How would you prefer to receive your wellness plan?
Supplements only
Lifestyle plan + supplements
Not sure yet, want a provider to help decide
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