Questionnaire A

This questionnaire is for new patients.
It's a long questionnaire, one that is as thorough as possible.
It's in your best interest to not skip any questions.
The more we know about you, the better we can help you.

The questions that are mandatory are marked with a symbol

Disclaimer: All our of products are sulfate free.

  • Basic Information
    Current Address
  • Basic Information
    What kind of Lifestyle do you lead?
  • 1. Hereditary Illness
    Is there a family history of the following:
  • 2. Serious Illnesses
    Have you had any of the following:
  • 3. Surgical Operations
    Have you had any of the following:
  • 4. Women
    Monthly periods
  • 5. Blood circulation
  • 6. Personal Habits
  • 7. Digestion
  • 8. Other Problems
    Sexual Problems
    Vision-related Problems
  • 9. Nervousness
  • 10. Anxiety
  • 11. Depression
  • 12. Sleep
  • 13. Weight History
    Check the time period when you first gained excessive amount of weight and other times after. Check as many as apply:
  • 14. Blood Test
    If you have not taken the necessary blood tests within six months, then, we will require you to take them at your Doctor's office. If you do not have a doctor of your own, then we can recommend one to you. NOTE: If you are in CA or NY, you must go to one of our trusted doctors
  • 15. Other Tests
  • 16. Pulse
  • 17. Electrocardiogram
  • 18. Medical Treatment
    If yes, are you taking any of the following:
  • 19. Allergies
  • 20. Measurements (Optional)
    Measure and write-in your measurements for each area
  • 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 Requirements
    By requirements of the FDA, please answer the following questions

  • 26. Affected areas
    Please draw on the diagram below to indicate the places where you would like to lose weight

  • 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.