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. You will be contacted shortly by one of our Health Advisors to set up the date and time of this call.
First Name
Middle name
Last Name
Age
Gender
Male
Female
Weight and Height
Weight (pounds):
Height (feet):
Date of birth
dd: yyyy:
Place of birth
Address
City
State / Province
Zip Code
Country
Occupation (Please write up to four words).
How did you Hear about Sanoviv?
USANA
In a Lecture
By a Person
Internet
Other
In a Magazine or Books
Genetic background
Caucasian
African American
Latin American
Indigenous / Native American
Asian
Other
Have you previously been a guest at Sanoviv?
Yes
No
Just visiting, did not have any treatments
What do you hope to achieve at Sanoviv?
What is the diagnosis that you have received? (Please include date of the diagnosis).
If you do not have a diagnosis, what is/are your main health issues?
What are your symptoms?
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?
Are you taking any medication or nutritional supplements? Please describe.
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 done? If the answer is yes, please mention the name of the tests, dates and results.
What do your doctors say about your condition?
Are you interested in CCSVI procedure?
Yes
No
I have no answer
Have you ever been diagnosed with a mental illness?
Yes
NO
I have no answer
Have you ever been hospitalized for mental/emotional problems?
Yes
NO
I have no answer
Do you have any sensitivities or allergies to food or medication?
Yes
NO
I have no answer
Preferred phone number to receive Sanoviv´s call, please include the country code, area code and phone number.
Home Phone:
Cell:
Other:
To ensure the quality of our service and to promptly respond to any of your inquiries, please write down your email address if you have one. We will email you to do follow up in case we cannot reach you by phone. Email address:
