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  • How frequently do you feel apathetic, experience mood swings, or lose interest in activities?*
  • How often do you suffer from migraine headaches?*
  • How regularly do you feel tired or exhausted?*
  • Have you experienced any recent sugar cravings or sensitivities?*
  • Have you experienced a decrease in competitiveness, self-esteem, or work performance?*
  • Have you noticed a decrease in mental sharpness, concentration, or focus?*
  • Have you experienced a decrease in sex drive, morning erections, or ejaculations?*
  • Have you noticed an increase or decrease in your sleep duration or quality?*
  • Do you experience excessive sweating?*
  • What is your age range?*
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    • Date of Birth*
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1630 Wilkes Ridge Parkway
Suite 105
Henrico, VA 23233

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