Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Are you pregnant? *

Yes

No

Are you breastfeeding? *

Yes

No

Do you have, or have you ever had any of the following: *

Select all that apply

Type 1 Diabetes

Type 2 Diabetes

Kidney Disease

Liver Disease

Gallbladder Disease

Have you ever had an eating disorder, anorexia nervosa, bulimia, or disordered eating: *

Yes

No

Have you ever tried intermittent fasting or fasting of any type: *

Yes

No