Amino Acid Therapy Assessment
Please provide accurate information to help us assess your suitability for amino acid therapy.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Do you have any diagnosed medical conditions?
*
Yes
No
Please list any diagnosed medical conditions (if any):
Are you currently taking any medications or supplements?
*
Yes
No
Please list your current medications or supplements (if any):
Do you have any known allergies?
*
Yes
No
Please list your allergies (if any):
In the past month, how often have you experienced the following symptoms?
*
Rows
Never
Rarely
Sometimes
Often
Always
Fatigue
1
2
3
4
5
Mood swings
6
7
8
9
10
Difficulty concentrating
11
12
13
14
15
Cravings (sugar, carbs)
16
17
18
19
20
Sleep disturbances
21
22
23
24
25
Low motivation
26
27
28
29
30
Anxiety or nervousness
31
32
33
34
35
Digestive issues
36
37
38
39
40
How would you rate your overall mood over the past two weeks?
*
1
2
3
4
5
How would you describe your current diet?
*
Balanced
High in protein
High in carbohydrates
Vegetarian/Vegan
Other
How many days per week do you exercise?
How many hours do you typically sleep per night?
What are your main goals or expectations for amino acid therapy?
*
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