Step 1: Health History If you are new to Heilen, please answer the questions below so that we can get to know you better. Please answer the questions below: ← BackThank you for your response. ✨ First Name(required) Last Name(required) Email(required) Phone(required) Are you currently being treated for any of the following: cancer, kidney disease, heart disease, and or pancreatic disease?(required) Yes No Was in past but not currently Have you ever been diagnosed with an inflamed gallbladder or cholecystitis?(required) Yes No Have you ever been diagnosed as having Schizophrenia?(required) Yes No Are you currently type 2 diabetic?(required) Yes No Was in past but no longer Have you ever been diagnosed as having hypertension or high blood pressure?(required) Yes No Have you been diagnosed with hypothyroidism?(required) Yes No If you are currently taking prescription medications, how many different medications are you currently on? (Do NOT include nutritional supplements)(required) None 1-3 4-6 7-10 >10 If you could only choose one goal to achieve, what would it be?(required) Weight Loss Decrease Body Inflammation Increase Energy Improve Blood Chemistry Decrease Joint Pain Sleep Better Other Is there anything that could prevent you from completing a health rebuilding program?(required) No Financial Lack of Support at Home Not Committed Work Life Stress Other If you have any comments or concerns, please list below: Do you have any food allergies?(required) Yes No If YES to food allergies, please list foods that you are allergic to below. Are you a female that is currently pregnant or nursing?(required) Yes No If your employer/organization has already enrolled you, what is the name of your employer/organization? (optional) Submit Δ You will be contacted within one business day! Thank You! Like Loading...
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