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Initial Questionnaire

Initial Questionnaire

Full Name
Full Name
First
Last

Please rate CRAVINGS from 1 to 5.

1 = Not at all. 2 = Occasionally. 3 = Can do without it. 4 = Must have it daily. 5 = Constantly.

Sugar
Caffeine
Chocolate
Ice Cream
Cookies
Alcohol
Candy
Marijuana
Tabacco
Diet Soda Pop
Soda Pop
Cake
Opioids
Heroine
Cocaine
Crystal Meth
Crack
Drugs

Please rate CRAVINGS from 1 to 5.

1 = Not at all. 2 = Occasionally. 3 = Can do without it. 4 = Must have it daily. 5 = Constantly.

Sugar
Caffeine
Chocolate
Ice Cream
Cookies
Alcohol
Candy
Marijuana
Tabacco
Diet Soda Pop
Soda Pop
Cake
Opioids
Heroine
Cocaine
Crystal Meth
Crack
Drugs
This combination homeopathic remedy has not been evaluated by the Food and Drug Administration.

This product is not intended to diagnose, treat, cure of prevent any disease.

All information is confidential. Only first name or first name and last initial or initials will be used to compile data.I have read the above statements and agree.

If the form does not go through, double-check that you completed all the fields marked with an asterisk as they are required.