Please fill out the health form below. This will need to be completely filled out and submitted before we send the HCG.
HCG Diet Questionnaire
Name
Address
City
State
Zip code
Email
Home Phone:
Cell Phone:
What is your height?
What is your weight?
Sex:
Female
Male
What is your date of birth?
Are you pregnant?
No
Yes
Are you diabetic?
Yes
No
Do you use tobacco?
Yes
No
Do you use alcohol?
Yes
No
Do you use recreational drugs?
Yes
No
If yes to above question, please list them here:
Please list and describe any allergies and adverse reactions to medications that you have had. If none, state "None":
Please list all the prescription medications, non-prescription medications, and supplements you are currently taking:
Do you have an important family history of any disease or condition?
No
Yes
If so, list here:
Do you have any condition that would indicate that you should not participate in this protocol?
No
Yes
Have you read the FDA Statement regarding HCG?
*
Yes
No
Do you still want to participate in the program?
*
Yes
No
How did you find out about HCGDiettips.com?
Google
Yahoo
Bing
Other
If a specific person or site referred you, please type it here:
Before starting any diet or exercise program, you must consult your primary physician. You will receive a phone call from our doctor. He is a consulting physician working in concert with your primary physician on your weight loss program. Please fax any recent physical/records to (800) 905-7112.
Submit
Should be Empty: