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Restore Your Health Survey

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Restore Your Health Survey

Would you like to restore your health? Get a FREE analysis!

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GenderMaleFemale

Age

DO YOU HAVE ONE OR MORE SYMPTOMS OF HORMONAL DEFICIENCY?Decreased StrengthAbdominal FatDecreased Libido (sex drive)Poor Sleep QualityJoint StiffnessHot FlashesFibromyalgiaHigh CholesterolDecreased Energy & StaminaDecreased Mental SharpnessThinning HairDepressionProstate Problems (men)Polycystic Ovary Syndrome (PCOS - women)Difficult Periods (women)Fibrocystic Breasts (women)Hysterectomy (women)

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

Please state your health objectives.

Example: I want to lose weight

Other symptoms you may have.

Example: I'm not feeling as good as I should and the doctors is telling me everything is fine.

Any other Health Factors?

Leaf Blanc

949-220-4742

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Stoughton, Massachusetts 02072

These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.

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