Request for FREE hA2cg Evolution Diet Health Assessment

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

Month Day 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 *

Male Female
Age (in years) *

0-17 18-39 40-49 50 & older
Enter Your Current Weight & Height *
How Many Pounds (Weight Loss) Would You Like Lose? *
Have You Used HCG Weight Loss Products Before? *

Never within the past one month within the past two months within the past three months within the past six months over 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? *

Yes No
Do you get infections easily? *

Yes No
Are you currently taking Antibiotics? *

Yes No
Do you have Diabetes? *

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

Yes No
Do you have high blood pressure? *

Yes No
How many blood pressure medications are you taking? *

none one two three four or more
Have you ever been diagnosed with Cancer? *

Yes No
Do you have active cancer? *

Yes No
Are you pregnant? (Females Only)

Yes No Maybe
Do you have Tuberculosis? *

Yes No
Do you have Gall Bladder Problems? *

Yes No
Do you have Gout? *

Yes No
Do you have Angina? *

Yes No
Are you taking Anxiety or Depression medications? *

Yes No
Are you a recovering alcoholic or drug addict? *

Yes No
Do you have problems with "Electrolyte Balance" or "Dehydration" ? *

Yes No
Do you have any current or past problems with "Cardiac Arrhythmia" ? *

Yes No
Please EXPLAIN and give details about any "YES" answer from the above questions:
Should be Empty:

Request for FREE hA2cg Evolution Diet Assessment