Please fill out this health questionnaire to get started immediately. As soon as we receive it, we will call you to set up an appointment.
Name: (First, Middle, Last)
Date of Birth:
GenderMale
Female
Address:
City, State, Zip Code:
email Address:
Confirm email Address:
Phone:
Cell Phone:
Best Time to Contact:Anytime ( 8 am - 9 pm)
Saturdays (8 am - 9 pm)
Mornings ( 8 am - 12 pm)
Afternoons ( 12 pm - 5 pm)
Evenings ( 5 pm - 9 pm)
Occupation / Hours per week
Health Information Section (Please fill out to the best of your knowledge.)
Health Care Provider
Primary Health Concerns
Past Hospitalizations/ Surgeries
Current Medications / Supplements
Known Allergies ( foods, drugs, environmental)
Exercise (type and hours per week)
Do you have a pacemaker?Yes
No
Do you or have you ever smoked? If so, how many packs per day?
What has been your heaviest weight, and when did you get to be that weight?
Have you had a recent change in weight? Please describe.
How many pounds would you like to lose on the HCG Program?
Nutrition and Diet Information
Do you drink alcohol? If so, how much per day?
Do you drink caffeine? If so, what type and how much?
Current special diet?
Past diets you have tried. Please describe any successes/failures.
Typical Breakfast:
Typical Lunch:
Typical Dinner:
Past and Present Health Conditions. Please check all that apply:
Headaches:Past
Present
Pain:Past
Present
Fatigue:Past
Present
Fibromyalgia:Past
Present
Fever:Past
Present
Night Sweats:Past
Present
Insomnia:Past
Present
Stress:Past
Present
Rash / Skin Problems:Past
Present
Arthritis / Painful JointsPast
Present
Osteoporosis:Past
Present
Bladder / Kidney Problems:Past
Present
Cancer:Past
Present
Gas / Bloating:Past
Present
Abdominal Pain:Past
Present
Constipation:Past
Present
Diarrhea:Past
Present
Thyroid Disfunction:Past
Present
Diabetes:Type 1
Type 2
Pregnancy:Past
Present
PMS / Menstrual Problems:Past
Present
Depression / Anxiety:Past
Present
Scoliosis:Past
Present
Spasms/ Cramps:Past
Present
Sciatica / Shooting Pain:Past
Present
Tendonitis:Past
Present
Disc Problem:Past
Present
Numbness / TinglingPast
Present
Heart Disease:Past
Present
Heart Murmur:Past
Present
Atrial Fibulation:Past
Present
Stroke:Past
Present
Blood Clots:Past
Present
High Blood Pressure:Past
Present
High Cholesterol:Past
Present
Chest Pain:Past
Present
Shortness of Breath:Past
Present
Dizziness:Past
Present
Asthma / Allergies / Hay Fever:Past
Present
Infection:Past
Present
Epilepsy / Seizures:Past
Present
Gout:Past
Present
Family History. Please describe any major health problems.
Father:
Mother:
Siblings:
How did you hear about our program?
Other Comments:
By filling in the name below and checking the "Accept" box, I acknowledge that I have fully read over and filled out the above health history questionnaire truthfully and accurately.
My Full Name:
Acknowledgement:I accept:
