Request for FREE hA2cg Evolution Diet Health Assessment

Request for FREE hA2cg Evolution Diet Assessment
Form Submission Date (No Need to Change)

MonthDay Year Hour Minutes AM/PM Option
Name:(First, Last)*
E-mail*

Confirmation Email
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Comments:
Gender*

MaleFemale
Age (in years)*

0-1718-3940-4950 & older
Enter Your Current Weight & Height*
How Many Pounds (Weight Loss) Would You Like Lose?*
Have You Used HCG Weight Loss Products Before?*

Neverwithin the past one monthwithin the past two monthswithin the past three monthswithin the past six monthsover six months ago
How Many Times Do You Exercise Weekly?*
How Long(in minutes) Are Your Exercise Workouts?*
Have you been diagnosed with ANY Auto-Immune Disease?*

YesNo
Do you get infections easily?*

YesNo
Are you currently taking Antibiotics?*

YesNo
Do you have Diabetes?*

Yes (Type 2)Yes (Type 1)No
Are you currently taking Chemotherapy?*

YesNo
Do you have high blood pressure?*

YesNo
How many blood pressure medications are you taking?*

noneonetwothreefour or more
Have you ever been diagnosed with Cancer?*

YesNo
Do you have active cancer?*

YesNo
Are you pregnant? (Females Only)

YesNoMaybe
Do you have Tuberculosis?*

YesNo
Do you have Gall Bladder Problems?*

YesNo
Do you have Gout?*

YesNo
Do you have Angina?*

YesNo
Are you taking Anxiety or Depression medications?*

YesNo
Are you a recovering alcoholic or drug addict?*

YesNo
Do you have problems with "Electrolyte Balance" or "Dehydration" ?*

YesNo
Do you have any current or past problems with "Cardiac Arrhythmia" ?*

YesNo
Please EXPLAIN and give details about any "YES" answer from the above questions:
Should be Empty:

Request for FREE hA2cg Evolution Diet Assessment