DISCOUNT-HUMAN-GROWTH-HORMONE.COM MEDICAL QUESTIONAIRE This form must be filled out before you place your order PLEASE, READ, PRINT, SIGN AND FAX IN THE INFORMED CONSENT AGREEMENT CLICK HERE ALONG WITH THE MEDICAL CONSENT FORM BELOW. Fax To: 775-307-4172

CLIENT CONTACT DATA
Your name*
Email address*
Address*	No P.O. Box
City*
State*
Zip Code*
Country*	Select United States Canada United Kingdom ----------------------- Albania Algeria American Samoa Angola Anguilla Antigua & Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belarus Belgium Belize Benin Bhutan Bolivia Bonaire Bosnia & Herzegovina Botswana Brazil British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Rep Chad Chile China Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Curacao Cyprus Cyprus (Northern) Czech Republic Dem Rep of Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kosovo Kuwait Kyrghyz Republic Laos Latvia Lebanon Lesotho Liberia Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mexico Moldova Monaco Mongolia Montserrat Morocco Mozambique Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palestinian Authority Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Republic of Korea Reunion Romania Russia Rwanda Samoa Saudi Arabia Senegal Sierra Leone Singapore Slovakia Slovenia South Africa Spain Sri Lanka St. Kitts & Nevis St. Lucia St. Maarten St. Vincent Suriname Sweden Switzerland Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Island Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay US Virgin Islands Uzbekistan Vanuatu Vietnam Yemen Yugoslavia Zambia Zimbabwe
Home phone*
Best time to Call	-- Select -- 8 AM-10 AM 10 AM- Noon Noon- 3 PM 3 PM- 6 PM 6 PM- 9PM
Work phone
Best time to Call	-- Select -- 8 AM-10 AM 10 AM- Noon Noon- 3 PM 3 PM- 6 PM 6 PM- 9PM

CUSTOMER DETAILS
Date of Birth		Your Physician´s Information
Age		I have a Physician	Yes No
Height		Physician´s Name
Weight		City
Sex	Male Female	State
Occupation		Phone Number

First time users must complete this medical history form, existing customers can skip the rest of this form provided we have a Medical History on file for you. Do you have a medical history on file with us?

Yes No

FAMILY MEDICAL HISTORY
Do you have a history or early finding of the following?
Diabetes, thyroid or other	Yes No	Endocrine Disorder	Yes No
Hypertension	Yes No	Lipid Disorder	Yes No
Cardiovascular disease	Yes No	Prostate Cancer	Yes No
Other forms of Cancer	Yes No	Illnesses not previously noted	Yes No

CLIENT MEDICAL HISTORY
Do you have a history or early finding of the following?
Pregnant/Lactating	Yes No	Blood disorders	Yes No
Cancer	Yes No	Immune disorders	Yes No
Poor wound healing	Yes No	Edema / excess fluid retention	Yes No
Hyperlipidemia	Yes No	Upper respiratory	Yes No
Lung disorder	Yes No	Hypertension	Yes No
Renal disease	Yes No	Heart Attack	Yes No
Emotional disorders	Yes No	Genital-Urinary disorder	Yes No
Glaucoma	Yes No	Carpal Tunnel syndrome	Yes No
Surgery	Yes No	Drug allergies	Yes No
Other illness not yet noted:	Yes No	Chemical Dependency	Yes No
Loss of concentration	Yes No	Decreased energy	Yes No
Decreasing sociability	Yes No	Decreased endurance	Yes No
Decreasing activity	Yes No	Increasing mood swings	Yes No
Decreasing memory	Yes No	Increasingly stressed	Yes No
Decreased desire to exercise	Yes No	Difficulty sleeping	Yes No
Decreased sense of well-being	Yes No	Increased lack of drive	Yes No
Loss of interest in sex	Yes No	Depression	Yes No
Decreasing size of testicles	Yes No	Vaginal dryness	Yes No
Urogenital atrophy	Yes No	Hot flashes	Yes No
Cold or heat intolerance	Yes No	Thinning or loss of hair	Yes No
Increasing wrinkles	Yes No	Sagging, loose or thin skin	Yes No
Increasing sagging muscles	Yes No	Muscle loss	Yes No
Decrease muscle strength	Yes No	Progressive osteoporosis	Yes No
Increasing fat deposits about abdomen or thighs	Yes No	Have you ever been on an HGH Program before?. If 'yes', how long ago?	Yes No