First Name
*
Last Name
*
Email
*
Do you have frequent diarrhea or loose stools?
*
Yes
No
Do you have acne, eczema, hives, itching, rashes or skin issues?
*
Yes
No
Do you experience rectal or anal itching?
*
Yes
No
Do you grind your teeth while sleeping?
*
Yes
No
Do you have hyperactive or nervous tendencies?
*
Yes
No
Are you irritable for no apparent reason?
*
Yes
No
Do you kiss your pets or allow your pets to lick your face?
*
Yes
No
Do you have anemia, low iron, B6, or zinc levels?
*
Yes
No
Do you swim in creeks or lakes? (or have in the past)
*
Yes
No
Have you ever traveled to developing nations?
*
Yes
No
Do you eat pork, sushi or raw fish?
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Yes
No
Do you have strong sugar and processed food cravings?
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Yes
No
Do you have apathy, lethargy, low motivation?
*
Yes
No
Do you homestead, live on a farm, or play in the dirt?
*
Yes
No
Do you feel bad or have symptoms flair during a full moon?
*
Yes
No
How many questions above did you mark 'Yes' to??
*
Less than 4
5 to 8
9 or more
Submit