Health Questionnaire

The time is 1:03:20 PM on August 04 2017

To begin ordering, you must fill out the Health Questionaire. Please fill in all of the required areas in blue text. No order can be filled without the completion of this Health Questionaire. You must be at least 18 years of age to begin treatment. Always consult with your doctor before taking any new treatment. If you have any questions, please call us at: 1-800-511-5706 Monday thru Friday from: 9am to 4pm EST

If we need to contact you. Which is your preferred method?:

What Are Your Goals?
Your Lifestyle
Medical History

Please carefully review all of the health problems listed below. Do you have any of these medical problems?

Abdominal pain, Nausea/vomiting, Constipation, Diarrhea, Colitis, Diverticulitis, Hiatal hernia/reflux disease, Irritable bowel syndrome, Ulcers, Pancreatitis, Rectal Bleeding/rectal pain, Change in bowel habits, Hemorrhoids, Uterine problems, Ovarian problems, Infertility, Bleeding between periods, Wheezing, Shortness of breath, Productive or bloody cough, Asthma, Emphysema/COPD, Bronchitis, Pneumonia, Sleep apnea, Pulmonary embolism, Chest pain (Angina), Palpitations/heart racing, Congestive heart failure, Heart attack, High blood pressure, Pacemaker, Heart valve, Rheumatic fever, Swollen glands, Anemia, Cirrhosis, DVT/phlebitis/blood clots, Jaundice, Lupus, Bleeding disorders, Scleroderma, Kidney problems/stones, Bladder infections, Kidney failure, Hernia, Numbness/tingling, Loss of strength, Stroke (CVA/TIA), Headaches, Seizures/epilepsy, Multiple Sclerosis, Ear problems, Eye problems Nose/sinus problems.Throat problems, AIDS/HIV, Hepatitis A/B/C, Sexually transmitted disease, Tuberculosi, Nervousness, Anxiety, Depression, Cancer of any type.

If yes, please descibe below:

If yes, please descibe below:

Your Order

Where will your products be shipped? Please fill in your complete address. Please double check your address for any mistakes before you submit. If you live in an apartment, please include your unit #. We are not responsible if you do not put in your correct address.

Your Shipping Address:

Is your shipping address the same as your billing address? (Your billing address is where your credit card statements are mailed to).

If it`s not the same, please fill in your billing address below:

Your Billing Address:

How To Make Payment

*If your Health Questionnaire is accepted, then you can make payment for the products you wish to purchase. A customer representative will contact you by e-mail after they review your health questionnaire. Most questionaires are accepted & approved (97%) within the day of submission. We have 2 options for payment. Please choose your payment method.

would like to make payment by:

We implement the highest standards and state of the art security measures to keep your electronic check information and transactions safe and secure. We use banking standard 256-bit encryption. If you ever have questions or concerns, please call our center at: 1-800-511-5706, Monday-Friday 9am to 4pm est.

Terms of Service

*Please read and agree to our Terms of Service. Check the boxes below and submit questionaire:

These products are not intended to diagnose, cure, or prevent any disease. These statements have not been evaluated by the Food and Drug Administration. Consult with a physician prior to use. Must be 18 years of age.
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