Pre-enrollment Questionnaire

Your current health situation, lifestyle, and personal commitment to this self-help program must be discussed during your FREE phone or email consultation. A prior knowledge will help to facilitate the discussion and minimize phone expenses if a phone call is preferred.

Please answer the following questions as best as possible and agree to the terms of enrollment and we will contact you via your email address.

This Form cannot be submitted until the missing fields (labelled below in red) have been filled in
Associate Health History
Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name*
E-Mail Address*
Street Address*
City*
State/Prov*
Zip/Postal Code*
Country*	CountryUnited StatesCanada----------------AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntiguaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribadiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoFederated States of MicronesiaMoldovaMonacoMongoliaMontserratMoroccoMontenegroMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaS. Georgia and S. Sandwich Isls.Saint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamUS Virgin IslandsWallis and Futuna IslandsWestern SaharaYemenYugoslavia (former)ZaireZambiaZimbabwe
Home Phone*
Fax
Date of Birth*
Sex*
Marital Status*
Number of Children*
Height & Weight*
Do you consider yourself to be in good health? ..... If not, why?*
What do you consider to be your primary health problem?*
What other health concerns do you have?*
What medical or self-help approaches have you tried or are you currently using?*
Please provide a brief description of daily activities and exercise:*
Please provide a brief description of your current diet .*
How did you find us or hear about us?*
Please read our Enrollment Terms: Student Agreement, Legal Disclaimer and Privacy Policy. Please check all boxes that apply.	A. I Have Read the Student Agreement, Disclaimer and Privacy Policy of NHRA B. I ACCEPT full responsibility for my health choices and the results of my research. C. I will keep a Weekly Diary and share data with NHRA. D. I agree not to reproduce or distribute any information provided to me by NHRA. E. I understand that my personal records will be kept confidential by NHRA.
Please enter the word that you see below.