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* 1. First Name

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* 2. Your Email Address

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* 3. On a scale from 1 to 5, with 1 being the least stressed and 5 being the most stressed, how stressed are you?

  1 Least Stressed 2 3 4 5 Most stressed
How stressed are you?

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* 4. What's the cause of your stress? Check as many as appropriate.

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* 5. Tell Us Your Zip or Postal Code

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