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Full Name
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Gender
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Age (in years)
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City of Residence
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Occupation
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Where did you hear about us ?
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What are your primary health concerns? (Mention top 3–4) *
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Since how long have you been facing these issues? *
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What treatment have you taken so far? *
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Do you have any diagnosed conditions?
Thyroid issues
Diabetes (Type 1 or 2)
PCOD/PCOS
Fatty Liver
Hypertension (High Blood Pressure)
Lipid issues (High Cholesterol/Triglycerides)
Autoimmune condition
Others (Please specify in the next question)
any the primary
If 'Others' then please specify details here.
Are you currently taking any medications? If yes, please mention the name, dosage, and duration of use.
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Do you have recent blood reports (last 3–6 months)?
Yes
No
Are you willing to commit to a structured 6-month health correction program? *
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Yes
Not Sure
This is a premium, structured, supervised program. Are you ready to invest in long-term health correction rather than short-term dieting?
Fully ready and willing to commit
Ready, but would like more clarity about the structure
Exploring options, not yet fully committed
Looking for a shorter / quicker solution
On a scale of 1 to 5, how motivated are you to start making significant health changes right now?
1
2
3
4
5
Why do you want to start this now?
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