Clinical study requires free Acrobat reader

Testimonial of a 29 year old male
 

General Health Questionnaire and Consent Form
 Items with a * are required.

Last Name *
 First Name *
 Date of birth (mm/dd/yyyy) *
Address *
 Height
Feet Inches
City *
 State *
 Zip *
 Weight
Pounds
Phone (xxx) xxx-xxxx *
 Fax (xxx) xxx-xxxx
 Marital Status
E-Mail Address *

Place of employment:
 Phone: (xxx) xxx-xxxx

  • How is your health in general?   Poor   Fair   Good   Excellent

    • Do you smoke?   If YES, how many packs per day?

    • Alcohol use (Drinks)      Coffee/Tea Use (Cups)     Regular Decaf

      List prescription medications and
      over the counter drugs and dosages:
      		 Supplements
      (i.e.: vitamins, herbs, minerals,etc.):


      List allergies to drugs or medications:

      Major illnesses:
      Heart Problems
      Heart Murmur
      Epilepsy
      Heart Disease
      Heart Attacks
      Pacemaker
      Neck Pain
      		 Cancer
      Rheumatic Fever
      Headaches
      High BP
      Jaws click
      Clench or grind teeth
      Ringing in ears
      		 Hepatitis
      Kidney Disease
      HIV Pos. or Aids
      Diabetes
      Yeast infect.
      Urinary tract infect.
      Other

      Surgeries:

      Accidents or major injuries:

      Information is submitted for analysis. Clients must be 21 years of age or older. Certain conditions preclude the use of Trans-D Tropin. Those with cancer or pituitary adenoma, as well as pregnant or lactating women should not use Trans-D Tropin. Clients uncertain of these conditions should obtain either a Somatomedin-C or Prolactin blood test. Failure to obtain a blood test, or the presence of unrevealed conditions, or the presence of any contra indications for the use of Trans-D Tropin, results in the client accepting the goods and services At Their Own Risk.