Free Gift Questionnaire

Congratulations on choosing 'The DetoxNow'. Please answer these few basic questions to help us identify what you and your fellow detoxers need. This information is secure and confidential. This data is gathered as informational only to support marketing the right programs and not intended to act as a medical screening.
1. Do you have a primary health concern or affliction that you know of?
2. If you answered 'yes' to the previous question and you know the name of your affliction; please enter it here.
3. How long have you been suffering from symptoms?
1 week or less1 - 6 weeksSeveral monthsMore than a year
Answer 1
4. Have you ever had surgey?
5. (Female) Have you ever been on a contraceptive pill?
6. Do/did you eat meat or dairy products?
7. Are you currently a vegan? If so, for how long?
YesNo
Less than a month
Several months
More than a year
8. Do you purchase organic produce?
9. List the typical foods you eat on a daily and weekly basis.
Use commas to seperate items on your list.
Breakfast
Lunch
Snacks
Dinner
Cool drinks
Hot drinks
10. Do you eat out regularly?
11. Do you eat soy products?
12. Do you ever eat flaxseed, beets or carrots?
* 13. Are you currently taking any prescription medication?
14. (Optional) Please list all of the prescription medications you are currently taking.
Prescription 1
Prescription 2
Prescription 1
Prescription 1
Others
15. Do you have anyallergies?
16. Do you have any respitory disorders (not mentioned above)?
17. Have you ever had cancer?
* 18. Please enter the email address where we will send your free gift.