Please enable JavaScript in your browser to complete this form.Name First & Last *Email Address *May I add you to my email list?YesNoWhat are your three major complaints?How long have these complaints bothered you?What is the frequency of your symptoms that your experiencing?What have you done in the past to try and resolve these complaints? Are you going backwards or just maintaining?What does this issue prevent you from doing?Where would you like to see yourself in 6 months to a year from now? Or What would better health (sleep, happy outlook, calm approach to life) do for you?Do you have any medical diagnosis?On a scale of 1-10, what is your commitment level, 1 no commitment 10 100% dedicated? *Please Choose One1 – Not Today!2345 – Maybe678910 – Totally Dedicated!CommentSubmit