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	Do you carry your weight in your belly area?* Yes No
	Have you developed back fat?* Yes No
	Have you been under a lot of stress?* Yes No
	On a scale from 1-10. What is your stress level?* Please Select 1 2 3 4 5 6 7 8 9 10
	How many hours of sleep do you get per night?* Please Select Under 4 Hours 4 - 6 Hours 6 - 8 Hours Over 8 Hours
	Do you have a problem sleeping through the night?* Please Select Yes No Sometimes
	Do you find yourself emotionally eating?* Yes No
	Are you craving sugar and carb foods more often?* Yes No
	Have you become more irritable in day to day life?* Yes No
	Which clinic location would be best for you?* Please Select Scottsdale, AZ Mesa, AZ Peoria, AZ Maple Grove, MN National
	Name* First Name Last Name
	Phone
	Email*