» Quick hCG Medical Form

See If You Qualify!

HCG Medical Questionaire
Step One - Answer These Few Questions To Qualify For The hCG Diet Protocol!
All fields marked with * are required!
First & Last Name*
Email Address*
Phone With Area Code*
Street Address*
City*
State*
Zip Code*
Date of Birth*
Gender*
Height*
Weight*
Date of Last Diet* if you've never dieted enter: none
How Much Weight Did You Lose?* if you never lost weight enter: none
How Much Have You Regained?* if you never gained enter: none
List Any Medications You Take* if you don't take any enter: none
List Any Hormones You Take* if you don't take any enter: none
History of Cancer*	Yes No
If Yes, Please Explain
History of Diabetes*	Yes No
If Yes, Please Explain How many units of insulin? etc.
History of High Blood Pressure*	Yes No
If Yes, Please Explain
Are You Pregnant?*	Yes No
Any Additional Information? (optional)
Disclaimer: We urge all our web site visitors to seek medical advice before beginning any weight loss program, exercise, training regime or any diet. While the contents of this web site have been provided in good faith, no warranty is given as to the accuracy or effectiveness or safety or any of the comments, suggestions or information provided herein. As a condition of access and use of this website, readers must agree that, before embarking on any form of diet, exercise program or other treatment (broadly defined), they will consult their own doctor or other health care professionals face-to-face and discuss any matters found on this website that may apply or be of interest. Statements on this site have not been evaluated by the FDA.

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