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Herpes Personal Care Survey
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Herpes Personal Care Survey
Your name *
Email address *
Location *
What is your age? *
What is your gender? * Male Female
What Type of Herpes do you have
How often do you have outbreaks
Do you take any supplements or pills to control outbreaks? Yes No
If you take pills/supplements please state the name
Are you getting good results from the pills? Yes No I don't know yet
Other details
 
* Required
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