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1.
Please fill in the following
(Required.)
Name
Address
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number
2.
With which gender do you identify?
(Required.)
Male
Female
Non-binary
Other (please specify)
3.
What are your preferred gender pronouns?
(Required.)
He/Him
She/He
They/Them
Other (please specify)
4.
With which ethnicity do you most identify?
(Required.)
White
Black or African American
Hispanic or Latino
Asian or Asian American
Other (please specify)
5.
To which age group do you belong?
(Required.)
Under 21
21-38
39-56
57-74
75+
6.
What is your exact age?
(Required.)
7.
Are you currently under a physician’s care for the treatment of any of the following?
(Required.)
Type 2 Diabetes
Type 2 Diabetes with Fatty Liver Disease
Obesity
Gastro-esophageal reflux
Heart Failure
Hypertension (high blood pressure)
Dyslipidemia (unhealthy levels of one or more kinds of fat in the blood)
Obstructive sleep apnea
Polycystic ovarian syndrome (female subjects only)
Chronic kidney disease
Gallstones
Osteoporosis
Pain, anxiety and/or depression
Legally Blind
Legally Deaf
Other (please specify)
None of the above
