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Full Name

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Do you have trouble losing weight?

Yes

No

How often are you tired?

Everyday

3 Times a week

Sometimes

Never

Do you have high blood preasure?

Yes

No

How often do you eat fast food?

Everyday

3 times a week

Once a week

Once per month

Never

How often do you train?

Everyday

3 times a week

Once a week

Once a month

Never

Do you have diabets?

Yes

No

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