CELLECT

Questionnaire

We would appreciate if you would complete this questionnaire. This information will give us a better understanding of your viewpoints and it will help support our efforts to understand the body's chemistry requirements and how to not only control it, but also to better educate our society in an effort to provide a more enjoyable life for all. Please provide us with any information that you feel will help us to serve you more efficiently and will help us to help others as well.

Contact Information

Name:
Address:
City: State/Province: Zip or Postal Code:
Country: Referred By: E-mail Address:
Phone Number: Fax Number: Best Times to Call:
Date of Birth (optional)

Type of Illness: Diagnosis Date:

What were the early symptoms leading to exam:

Describe the basic situation:

Treatments Received:

Initial diagnostic tests & lab work done (include dates & results):

Approximate date of beginning the vitamin program:

Status at start of vitamin program:

Please describe your current status. Please be sure to note any improvements or worsening of symptoms as well as any ancillary effects not related to your illness:

List any substantiating evidence of your results or experiences such as MRI, CT scan, blood work, other test results, etc. (including dates) since starting the CELLECT

vitamin program:

Would you be willing to share these records with us? They will be used to help other patients and doctors learn about the program. Your identity will be kept confidential:

Please briefly summarize your experience with the vitamin program thus far:

Did you have any difficulty taking the vitamins at any time? (please explain)

Is there anything you would like to add that may help others with similar illnesses?

Please provide any feedback you fell may be used to help us improve our services:

Would you like to be contacted by a CELLECT

advisor to discuss your current situation?

If you have any further questions, please indicate below:

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