Thank you for taking the time to fill out this questionnaire.
This will allow us to address your concerns and explain what Sanoviv can do for you. After submitting this form, please contact your admissions coordinator to schedule the date and time of your call.
* First Name
Middle name
* Last Name
Gender
Male
Female
Date of birth
dd yyyy:
* Address
* City
State / Province
Zip/ Postal Code
Country
Occupation (Please write up to four words).
Preferred phone number to receive Sanoviv´s call, please include the country code, area code and phone number.
* Home Phone
* Cell
Skype account
* Email Address
Religion
Marital Status
Person to contact in case of emergency
Phone number of contact person
Relationship with contact person
What is your primary language?
Do you require translation in order to communicate in English?
Yes
No
How did you hear about Sanoviv?
Online Search
Friend, Relative
Doctor Referral
USANA
In a Lecture
In a Magazine, Books
Other
Please summarize your current health status.
What is the diagnosis that you have received? (Please include date of the diagnosis).
If you do not have a diagnosis, what are your main health issues?
What do you want to achieve at Sanoviv?
In your opinion, What might have contributed or caused some of your main health complaints? Did anything significant happened in your life close to the time of onset?
Describe briefly the chronological evolution of your symptoms or/and diagnosis. Please include dates if possible.
What treatments have you done in the past and which ones are you currently receiving? Please specify dates if possible.
How physically independent are you?
Totally independent
I need help from others to move from one place to another
Have you had any medical tests recently? If yes, please list the name of the test, date, and result.
What do your doctors say about your condition?
Do you have any known food allergies (that will cause an anaphylactic reaction)
No
Yes
Do you have any known food sensitivities (those that may cause mild reactions)
No
Yes
Please note any food allergies or sensitivities for your companion, if applicable
Have you ever been hospitalized for mental/emotional problems?
Yes
No
Do you have any sensitivities or allergies to medication?
Yes
No
Have you had any surgery? if yes, elaborate.
Have you ever been diagnosed with an infectious disease?
Yes
No
In case of cancer, what types of chemotherapy or other treatments have you had?
Are you taking any medication or nutritional supplements? Please describe.
Are you taking any amphetamines (Adderall), Benzo (Valium, Xanax), or any antidepressant medications?
