Heart Rate Variability (HRV) Test

Answer the following questions about yourself:

1.
Do you experience episodes of fainting or dizziness when you stand?
Yes
No
2.
Are you encountering problems when urinating such as diminished feeling, urine leaks from bladder and inability to completely empty your bladder?
Yes
No
3.
For a male, are you unable to maintain an erection during sexual intercourse?
Yes
No
4.
For women, do you experience virginal dryness or problems with arousal and orgasm?
Yes
No
5.
Do you experience a problem when digesting food or from gastroparesis?
Yes
No
6.
Do you experience any of these conditions (diarrhea, nausea, vomiting, or abdominal boating)?
Yes
No
7.
Do you feel full after you have consumed a small amount of food or do you experience loss of appetite?
Yes
No
8.
Do you have heart burn that has persisted for some time?
Yes
No
9.
Have you been experiencing abnormal sweating that is usually decreased?
Yes
No
10.
Are you experiencing slow pupil reaction to light and darkness?
Yes
No
Please answer all of the questions before continuing.

Please provide us with your contact information to email your test results.

First Name:
Last Name:
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