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* 1. Using a scale from 1 to 10, where 1 is the worst and 10 is the best; what would you rate your overall health?

  1 2 3 4 5 6 7 8 9 10
.

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* 2. What are your specific health concerns?
ie. diabetes, high cholesterol, high BP

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* 4. What is your first and last name?

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* 5. What email address would you like to be contacted?

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* 6. What is the primary phone number to contact you in the next 24-48 hrs to resolve your health issues?

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