BIOHM Gut Report Lifestyle Questionnaire

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* What is your email address?

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* What is your sample ID#? (Found within your Gut Report Kit)

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* What is your gender?

Male

Female

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* What is your age?

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

If under 18, please specify below:

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* What is your height? (Please enter in inches)

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* What is your weight? (Please enter in pounds (lbs))

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* Which race/ethnicity best describes you? (Please choose only one.)

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic

White / Caucasian

Multiple ethnicity / Other (please specify)

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* In what state or U.S. territory do you live?

17% of survey complete.