FARMZ ASIA

Full Name *

Email *

Age *

Gender

Male

Female

Prefer not to say

Current height (in cm) *

Current weight (in kg) *

Waist circumference (in cm)

Brain Fog/ difficulty concentrating *

0 - Never

1 - Rare

2 - Occasionally

3 - Very Frequent

Frequent Headaches or Migraines *

0 - Never

1 - Rare

2 - Occasionally

3 - Very Frequent

Low Energy, sluggishness *

0 - Never

1 - Rare

2 - Occasionally

3 - Very Frequent

Mood Swings or irritability *

0 - Never

1 - Rare

2 - Occasionally

3 - Very Frequent

Anxiety or feeling overwhelmed *

0 - Never

1 - Rare

2 - Occasionally

3 - Very Frequent

Trouble falling or staying asleep *

0 - Never

1 - Rare

2 - Occasionally

3 - Very Frequent