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Questionnaire

Questionnaire B

This questionnaire is specifically made for returning patients who have or are currently undergoing treatment.
If you are a first-time patient seeking to start your treatment, click here: Questionnaire A.

The questions that are mandatory are marked with a symbol

If you run out of time after filling out the questionnaire, click on "Save my Progress" at the bottom of the page. This will allow you to finish your questionnaire at a later time. At least the first section has to be filled out to save your form

Disclaimer: All our of products are sulfate free.

  • Basic Information
     
    Current Address
  • 1. Nervousness
  • 2. Other
  • 3. Digestion
  • 4. Weight
    Would you like any changes made to your next formula?
  • 5. Medical Treatment
    C. Are you taking any of the following medications?
    If you answered 'yes' to any of the above, list name, strength, and dosage
    Are you taking any additional medications, including over the counter and/or herbal products. List name, strength, and frequency.
  • 6. Additional Questions - - If you have one of these specific problems
    Disclaimer: We correct your specific problems with homeopathic hormone dosages
    Sexual Problems
  • Your Doctor
    If you would like us to add your Doctor to our database and begin working with them, please add their information below.
  • FDA
    By requirements of the FDA, please answer the following question
  • Tell us what you think to help us improve
  • Legal
    By submitting this questionnaire, I hereby certify that:

    The above information is accurate and that I take full responsibility for following the guidelines of the program.

    I understand that my medical and prescription information will not be disclosed to any other party, except upon my authorization.

    I have read and agree with the Waiver and Consent Agreement.

    It’s not mandatory, but, we recommend strongly that you have a Comprehensive Hormonal Profile performed along with your mandatory Blood Tests.