Name
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First Name
Last Name
Email
*
Phone
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(###)
###
####
Date of Birth (MM/DD/YYYY)
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Gender
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Male
Female
Prefer Not To Say
Occupation
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Lifestyle
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Sedentary
Moderately active
Very active
Which of the following apply? (Check all that apply)
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Duration of symptoms:
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Impact on quality of life (1–10):
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Check any that apply:
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Are you currently taking any prescription medications?
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Are you taking any supplements or herbs?
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Check any categories that apply:
Have you previously received any of the following?
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Did any improve your symptoms?
Do you consume alcohol, processed foods, or smoke?
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Did you know...
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● NAD+ declines up to 50% between ages 40–60?
● Glutathione levels drop with age, toxins, stress, and medications?
● HGH declines ~14% per decade after age 30?
Primary Goals (Check all that apply)
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How soon are you looking to begin if approved?
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Which therapies are you most interested in?
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Preferred method of administration (if approved):
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Comfort with self-injection:
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Is there anything else you'd like our medical team to know about your health or goals?
