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* 1. Email:

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* 2. Name:

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* 3. Phone number:
(in case we have a problem contacting you though email)

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* 4. Age:

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* 5. City:

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* 6. Province:

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* 7. Are you a returning client?

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* 8. If yes, how would you rate your previous experience with us?

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* 9. What do you want out of your Staterra Supplement System?

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* 10. What is your height in feet and inches?

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* 11. What is your current weight in pounds?

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* 12. FEMALE SPECIFIC QUESTIONS
Please rate how often you experience the following:

  Always Frequently Sometimes Rarely Never N/A
PMS Symptoms
Menopause Symptoms
Yeast Infections

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* 13. Are you on hormonal birth control?

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* 14. Are you nursing, pregnant, or trying to become pregnant?

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* 15. GENERAL HEALTH QUESTIONS
Please rate how often you experience the following:

  Always Frequently Sometimes Rarely Never
Have trouble thinking or concentrating
Become easily confused
Have memory problems or forget things often
Lose your train of thought or the thread of conversations
Have little energy to do things or feel tired a lot
Feel depressed, blue or down most of the day
Feel fidgety or restless
Have trouble sleeping at night
Feel anxious and worried for a lot of the time
Experience migraine headaches
Experience tension or stress headaches
Constipation
Diarrhea
Bloating/gas/cramping/sleepy after eating
Indigestion or heartburn
Excessive body odour
Discomfort under right ribs
Strong cravings for sweets, coffee, and/or alcohol
Hungry within 3 hours of eating a meal
Stiff joints on waking 
Excessive soreness (lasting longer than 3 days) after a workout
Loss of strength
Joint pain throughout the day
Blurred vision
Poor night vision
Seeing spots
Diminished sex drive
Gain weight easily
Trouble loosing weight (even with diet and exercise)
Feel distinctly lethargic or sluggish

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* 16. Do you suffer from any medical conditions?

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* 17. Do you have any food allergies, sensitivities, or special dietary requirements?

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* 18. Do you take any medications or drugs?

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* 19. How often do you exercise?

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* 20. When you workout, how long do you workout for?

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* 21. Intensity of exercise:

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* 22. Is there any other health, fitness, or medical information not covered that we should know about?

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* 23. What flavour would you like for your custom formula? Note that all options are free of artificial flavours, colours, and fillers. 

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