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Cellular Health Complete Recommendation
Fill out the following medical form and within 48 hours we will contact you with a medical recommendation (prescription) determining which of these products can be an option for you.
Name:
*
Last Name:
*
Sex:
*
Select your Gender
Male
Female
this field is required.
Email:
*
Name of Your Physician:
*
Country:
*
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Phone Number:
*
Date of Birth:
*
Next
ADD/ADHD
Yes
No
Radiation Treatment
Yes
No
Chronic Sinus Problems
Yes
No
Rapid Weight Gain/loss
Yes
No
Heart Attack
Yes
No
Chronic Fatigue Syndrome
Yes
No
Circulatory Problems
Yes
No
Rheumatic Fever
Yes
No
Heart Disease
Yes
No
Gout
Yes
No
Headaches
Yes
No
AID/HIV Positive
Yes
No
Alcoholism
Yes
No
Convulsions/Seizures
Yes
No
Cortisone Treatments
Yes
No
Heart Pacemaker
Yes
No
Skin Rash
Yes
No
Arthritis/Rheumatism
Yes
No
Allergies/Hayfever
Yes
No
Anaphylaxis
Yes
No
Anemia
Yes
No
Shortness of Breath
Yes
No
Cosmetic Surgery
Yes
No
Angina Pectoris
Yes
No
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Herpes
Yes
No
Heart Murmur
Yes
No
Shingles
Yes
No
Heart Surgery
Yes
No
Hemophilla
Yes
No
Cough Persistent
Yes
No
Sleep Apnea
Yes
No
Hepatitis
Yes
No
Smoking
Yes
No
Crohn's Disease
Yes
No
Asthma
Yes
No
High Cholesterol
Yes
No
Diabetes
Yes
No
Back Problems
Yes
No
Kidney Disease
Yes
No
Systemic Lupus Eryth
Yes
No
Artificial Joint (Hip/Knee)
Yes
No
Depression
Yes
No
Anxiety
Yes
No
Irritable Bowel Syndrome
Yes
No
Dizziness / Fainting
Yes
No
Drug Addiction
Yes
No
Swelling Of Feet / Ankies
Yes
No
Latex Allergy
Yes
No
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High Blood Pressure
Yes
No
Snoring
Yes
No
Stroke
Yes
No
Jaw Pain
Yes
No
Blood Disease
Yes
No
Blood Transfusion
Yes
No
Emphysema/COPD
Yes
No
Thyroid Disease
Yes
No
Tobacco Use
Yes
No
Cancer
Yes
No
Tonsils Removed
Yes
No
Multiple Sclerosis
Yes
No
Tuberculosis
Yes
No
Osteoporosis
Yes
No
Liver Disease
Yes
No
Tonsilitis
Yes
No
Fibromyalga
Yes
No
Chemotherapy
Yes
No
Ulcerative Colitis
Yes
No
Epilepsy
Yes
No
Bruises Easily
Yes
No
Low Blood Pressure
Yes
No
Gall Bladder Problems
Yes
No
Glaucoma
Yes
No
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Veneral Disease
Yes
No
Chronic Ear Problems
Yes
No
Are You Being Treated For Cancer Of Any Kind?
Yes
No
May I Have Your Permission To Speak Directly With Your Physician(s) Regarding Your Treatment?
Yes
No
Have Your Ever Been Hospitalized?
Yes
No
Any Drug Or Food Allergies?
Yes
No
Do You Or Have Used Prescribed Medical Marijuana?
Yes
No
Do You Or Used Marijuana Recreationally?
Yes
No
Have You Ever Experienced An Adverse Reaction During Medical Treatment?
Yes
No
Any Other Medical Conditions Not Listed Above?
Yes
No
Comments / Expected Health Goals
*
This field is required.
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