Name *

First Name

Last Name

Phone

(###)

###

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TAKE THE QUIZ:

Do you feel excessively tired, especially in the afternoon?

Yes

No

Do you have difficulty falling and staying asleep?

Yes

No

Do you crave salt?

Yes

No

Do you tend to feel more awake in the evenings?

Yes

No

Do you feel the need for caffeine or other stimulants throughout the day?

Yes

No

Do you feel stressed almost all the time

Yes

No

Do you often feel irritable?

Yes

No

Do you experience heart palpitations?

Yes

No

Have you recently experienced unexplained weight gain, especially around the middle?

Yes

No

Do you get sick easily?

Yes

No

Do you often experience brain fog?

Yes

No