Hi, welcome to the CHEKD Initial Qualification Form.

We're going to ask you a few simple questions to make sure we're a good fit for each other. This should take 3 minutes to complete.

Click the START button to begin.
...What's your first name? *

...What's your last name, {{answer_kRoS2TXxK9Ib}}? *

...{{answer_kRoS2TXxK9Ib}}, what's the best email address to send you your results?

*No spam will be sent. *

{{answer_kRoS2TXxK9Ib}}, what's the best number for our expert team to reach you? *

What Zip Code would you be using CHEKD in? *

What's your Date of Birth? *

Please select your biological gender. *

Pick your #1 Health Optimization Goal *

{{answer_kRoS2TXxK9Ib}}, what is your personal #1 health goal with CHEKD? *

Ok, {{answer_kRoS2TXxK9Ib}}, so far so good.

Now we're going to ask you to rate a few things about yourself to personalize your journey with CHEKD...

Rate your Focus & Mental Concentration from 1-5 (1 being worst, 5 being the best) *

Rate your Sex Drive & Libido from 1-5 (1 being worst, 5 being the best) *

Rate your Body Energy Levels from 1-5 (1 being worst, 5 being the best) *

Rate your Current Weight and Body Mass from 1-5 (1 being worst, 5 being the best) *

What medications or supplements are you currently taking? (include amount of compound, type "none" if you are not taking any) *

What health issues and surgeries have you had? (type "none" if you have not had any) *

Have you ever been on any hormone, testosterone, estrogen, progesterone, thyroid or other similar health protocols? *

Do you have access to an HSA (Health Savings Account) or FSA (Flexible Savings Account)? *

What is your yearly income? *

{{answer_kRoS2TXxK9Ib}}, to best make sure we are a good fit for you, please answer as honestly as possible.

If you qualify for a Personalized Health Protocol, what's the highest range you would be able to afford monthly for all services? *

Where did you hear about CHEKD? (Twitter, Current Client Referral, Website, Podcast, Google, etc...) *

Thank you for completing the CHEKD Qualification Form.

Our team will touch base with you shortly.
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