First and Last Name

Email Address

Cell Phone Number

Mailing Address

Date of Birth: MM/DD/YYYY

Occupation

Current Weight

Goal Weight

Height

Personal Physician & Physician Address

Do you have headaches?

Do you tend to crave sweets?

Do you experience water retention or swelling?

Do you have a menstrual cycle?

If you still have a menstrual cycle, is it regular?

If you don't have a menstrual cycle, did you have a hysterectomy?

Are you taking any kind of hormone replacement cream or pill?

Are you taking a hypothyroidism medication?

Do you experience problems falling asleep?

Do you experience problems staying asleep?

Do you find you are easily irritated?

Are you taking medication for high blood pressure?

Are you taking insulin?

Have you been diagnosed with diabetes?

Have you ever had a heart attack?

Are you currently using any kind of steroids? (ie: cortisone shots, meds, inhaler)

Have you ever experienced a stroke?

Are you being treated for any kind of colon disorders? (ie: colitis, colostomy, IBS)

Are you being treated for any kind of neurological diseases? (ie: MD, MS, cerebral palsy)

Have you ever had banding or balloon surgery?

Have you been diagnosed with any kind of cancer in the last 3 years?

Are you presently undergoing radiation or chemotherapy?

Have you ever been anorexic?

Have you ever been bulimic?

Have you been diagnosed with systemic lupus?

Are you currently pregnant or breast feeding?

Have you been diagnosed with internal malignancy or blood dyscrasia?

Do you have any kind of kidney disease?

Do you have any kind of liver disease?

Do you have any kind of chronic heart disease? (ie: congestive heart failure, rheumatic fever)

Are you taking any other prescriptions that you haven't listed above? If so, please list them here:

I have reviewed this medical and believe the answers to be accurate to the best of my knowledge.  I understand this information determines my eligibility to participate in the Back to Basics program. I accept that the information provided by Human Fuel is not intended to treat or cure any diseases or to offer any specific diagnosis to any individual and that the information provided by Human Fuel is offered as-is, without warranty and I assume all risks from using the information or products sold herein.  I release Human Fuel of any and all liability from the information provided and all information, including health, medical, physiological or other.  I acknowledge that the Back to Basics program is not intended as a replacement/substitution for professional consultation with qualified practitioners, or services of a physician, health provider, or any trained health professional and therefore, the program does not allow medical advice of any kinds, these concerns should be addressed and discussed with my physician, heath caretaker, or registered dietician.

I agree that in no event shall Human Fuel or any of its officers, employees, agents or representatives be liable for special, incidental or consequential damages, whether a claim in contract, negligence, strict liability or otherwise.  In consideration of the sale of product I agree to indemnify and hold Human Fuel or any of its officers, employees, agents, or representatives harmless from any and all claims, expenses, losses and liability of any nature whatsoever arising out of handling and/or use of Human Fuel products, whether used alone or in combination with any other product.  I realize that changes may be made at any time without prior notice and if I have a medical problem, I will contact my physician for diagnosis and treatment.