Participation

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First Name

Last Name

Phone

Email

How did you hear about us?

Please check the box next to any aliments that you have.  If you have a family history of aliments you may list that information in the comment section at the bottom of the form.

 HEENT

Glaucoma

Cold Sores

Headaches

Migraines

GENITOURINARY

STD

Prostate Cancer

Benign Prostatic Hyperplasia (BPH)

Prostatitis

Urinary Tract Infections

Over Active Bladder

Erectile Dysfunction

CARDIOVASCULAR

Hypertension

Congestive Heart Failure

MI/Heart Attack

DERMATOLOGY

Acne

RESPIRATORY

Asthma

Bronchitis

Emphysema

GASTROINTESTINAL

Hemorrhoids

GERD (acid reflux)

Gastritis

Dyspepsia

Chron's Disease

Constipation

Diarrhea

Inflammatory Bowel Disease

Irritable Bowel Syndrome

IMMUNOLOGIC

Seasonal Allergies

NEUROLOGICAL

Neuropathy

Carpal Tunnel

Seizures

CVA/Stroke

TIA

PSYCHIATRIC

Anxiety

Alzheimer's

Depression

ENDOCRINE

Thyroid Disorder

Diabetes I or II

High Cholesterol

Lipid Disorder

Gout

Obesity

MUSCULOSKELETAL

Athlete's Foot

Lupus

Arthritis

Osteoporosis

Back Pain

HEMATOLOGICAL

Anemia

Sickle Cell

Hepatitis

OTHER

Smoker

Cancer

Fibromyalgia

COMMENTS