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Name:
Phone:
() -
E-mail:
State:
Age of denture cream user:
 
Have you used denture cream or powder?
Yes     No  
Have you had a blood test to test your copper and zinc levels?
Yes     No  
Have you been diagnosed with:
Hyperzincemia
Neuropathy
Nerve damage
 Copper deficiency
Elevated zinc levels
Zinc poisoning
Hypocupremia
Have you experienced Neuropathy symptoms, such as loss of sensation, numbness or tingling, poor balance, abnormal blood pressure and heart rate or loss of cognitive function?
Yes     No  
Are you diabetic?
Yes     No  
If so have you ever been diagnosed with diabetic neuropathy?
Yes     No  
Describe what happened:

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